Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP Environmental, Health, and Safety Guidelines for Health Care Facilities Introduction environment, and other project factors, are taken into account. The applicability of specific technical recommendations should The Environmental, Health, and Safety (EHS) Guidelines are be based on the professional opinion of qualified and technical reference documents with general and industry- experienced persons. When host country regulations differ from specific examples of Good International Industry Practice the levels and measures presented in the EHS Guidelines, (GIIP) 1. When one or more members of the World Bank Group projects are expected to achieve whichever is more stringent. If are involved in a project, these EHS Guidelines are applied as less stringent levels or measures than those provided in these required by their respective policies and standards. These EHS Guidelines are appropriate, in view of specific project industry sector EHS guidelines are designed to be used circumstances, a full and detailed justification for any proposed together with the General EHS Guidelines document, which alternatives is needed as part of the site-specific environmental provides guidance to users on common EHS issues potentially assessment. This justification should demonstrate that the applicable to all industry sectors. For complex projects, use of choice for any alternate performance levels is protective of multiple industry-sector guidelines may be necessary. A human health and the environment complete list of industry-sector guidelines can be found at: www.ifc.org/ifcext/enviro.nsf/Content/EnvironmentalGuidelines Applicability The EHS Guidelines contain the performance levels and The EHS Guidelines for Health Care Facilities include measures that are generally considered to be achievable in new information relevant to the management of EHS issues facilities by existing technology at reasonable costs. Application associated with health care facilities (HCF) which includes a of the EHS Guidelines to existing facilities may involve the diverse range of facilities and activities involving general establishment of site-specific targets, with an appropriate hospitals and small inpatient primary care hospitals, as well as timetable for achieving them. The applicability of the EHS outpatient, assisted living, and hospice facilities. Ancillary Guidelines should be tailored to the hazards and risks facilities may include medical laboratories and research established for each project on the basis of the results of an facilities, mortuary centers, and blood banks and collection environmental assessment in which site-specific variables, such services. Annex A provides a description of activities in this as host country context, assimilative capacity of the sector. This document is organized according to the following sections: 1 Defined as the exercise of professional skill, diligence, prudence and foresight that would be reasonably expected from skilled and experienced professionals Section 1.0 — Industry-Specific Impacts and Management engaged in the same type of undertaking under the same or similar Section 2.0 — Performance Indicators and Monitoring circumstances globally. The circumstances that skilled and experienced Section 3.0 — References professionals may find when evaluating the range of pollution prevention and control techniques available to a project may include, but are not limited to, Annex A — General Description of Industry Activities varying levels of environmental degradation and environmental assimilative capacity as well as varying levels of financial and technical feasibility. APRIL 30, 2007 1 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP 1.0 Industry-Specific Impacts American Society for Healthcare Engineering (ASHE) of the American Hospital Association (AHA), and the Green Guide for and Management 2 Health Care (www.gghc.org). These guidelines should be used The following section provides a summary of EHS issues to verify the adequacy of planning for new HCFs or renovation associated with health care facilities (HCF) which occur during of existing facilities. the operations phase, along with recommendations for their management. Recommendations for the management of EHS impacts common to most large industrial facilities during the 1.1 Environmental construction and decommissioning phases are provided in the Environmental issues associated with HCF include the following: General EHS Guidelines. • Waste management HCF Design Considerations • Emissions to air The design and functional layout of an HCF should ensure the • Wastewater discharges following: separation of clean / sterilized and dirty / contaminated materials and people flows; development and Waste Management inclusion of adequate disinfection / sterilization procedures and Waste from health care facilities (HCF) can be divided into two facilities; adequate space for the storage of recyclable materials separate groups. The first consists of general waste, similar in (e.g. cardboard and plastic) for pickup; selection of heating, composition to domestic waste, generated during administrative, ventilation, and air conditioning (HVAC) systems that provide housekeeping, and maintenance functions. The second group isolation and protection from airborne infections; design of water consists of specific categories of hazardous health care waste, systems to provide adequate supplies of potable water to as detailed in Table 1 below. reduce risks of exposure to Legionella and other waterborne pathogens; provision of hazardous material and waste storage Health care facilities should establish, operate and maintain a and handling areas; treatment and exhaust systems for health care waste management system (HWMS) adequate for hazardous and infectious agents; and selection of easily the scale and type of activities and identified hazards. Facility cleaned building materials that do not support microbiological operators should undertake regular assessment of waste growth, are slip-resistant, nontoxic, and nonallergenic, and do generation quantities and categories to facilitate waste not include volatile organic compound (VOC)-emitting paints management planning, and investigate opportunities for waste and sealants. minimization on a continuous basis. In addition to the guidance provided on solid and hazardous waste management in the Internationally recognized guidelines for design and construction General EHS Guidelines, the HWMS should include the of hospitals and HCFs include the American Institute of following components: Architects (AIA) and the Facility Guidelines Institute (FGI), the 2 Information in these EHS Guidelines is drawn predominantly from the World Health Organization (WHO), Safe management of wastes from health-care activities, Pruss et al. (1999). This document is currently under review by the WHO, and updated practices will be incorporated into future versions of this these EHS Guidelines, as necessary. APRIL 30, 2007 2 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP Waste Minimization, Reuse, and Recycling that off-gas volatile organic compounds (VOCs), or Facilities should consider practices and procedures to minimize products that contain persistent, bioaccumulative and waste generation, without sacrificing patient hygiene and safety toxic (PBT) compounds; products that contain considerations , including: substances which are carcinogenic, mutagenic or reproductive toxins (CMR) • Source reduction measures: • Use of efficient stock management practices and o Consider options for product / material substitution to monitoring (e.g. for chemical and pharmaceutical stocks), avoid products containing hazardous materials that including: require the product to be disposed as hazardous or o Small / frequent orders for products that spoil quickly special waste (e.g. mercury3 or aerosol cans), and and strict monitoring of expiry dates preferring products with less packaging or products o Complete use of old product before new stock is used that weigh less than comparable products that perform • Maximization of safe equipment reuse practices, including: the same function o Reuse of equipment following sterilization and o Use of physical rather than chemical cleaning disinfection (e.g. sharps containers) practices (e.g. using microfiber mops and cloths), where such practices do not affect disinfection and Waste Segregation Strategies meet relevant standards for hygiene and patient At the point of generation, waste should be identified and safety4 segregated. Non-hazardous waste, such as paper and • Waste toxicity reduction measures5: cardboard, glass, aluminum and plastic, should be collected o Consider options for product / material substitution for separately and recycled. Food waste should be segregated and equipment containing mercury or other hazardous composted. Infectious and / or hazardous wastes should be chemicals; products that may become hazardous identified and segregated according to its category using a waste when disposed; products made of polyvinyl color-coded system, as detailed in Table 1 below. If different chloride (PVC6); halogenated compounds7; products types of waste are mixed accidentally, waste should be treated as hazardous.8 Other segregation considerations include the 3 Use of mercury-based medical devices (e.g. thermometers and blood pressure following: devices) should be avoided and / or replaced, with preference given to digital and aneroid alternatives. Further information is available from WHO (2005), Mercury in Health Care, available at: • Avoid mixing general health care waste with hazardous www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf 4 For more information see Hospitals for a Healthy Environment, available at: health care waste to reduce disposal costs; www.h2e-online.org/docs/h2emicrofibermops.pdf 5 For more information on material and product substitution options in • Segregate waste containing mercury for special disposal. healthcare facilities, see Health Care Without Harm http://www.noharm.org/globalsoutheng/ Management of mercury containing products and 6 Products made of PVC may include intravenous (IV) bags, blood bags and associated waste should be conducted as part of a plan tubing, basins, hemodialysis equipment, patient identification bracelets, bedpans, inflatable splints, respiratory therapy products, stationary supplies, catheters, lab equipment, drip chambers, medical gloves, thermal blankets, alternatives (without compromising the quality of the medical service provided); internal feeding devices, and packaging. When burned at certain temperatures, conduct initial cleaning with a used solvent, and use fresh solvents for final PVC has the potential to release dioxins and furans, and other persistent cleaning only; adopt calibrated solvent dispensers and unitized test kits; and organic pollutants (POPs). reduce the variety of solvents used to minimize waste streams. 7 For example, minimize use of halogenated compounds through work practice 8 Staff should not attempt to correct errors of segregation by removing contents modifications including use of citrus-based solvents rather than xylene of a waste receptacle, or placing one receptacle inside another. APRIL 30, 2007 3 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP involving specific personnel training in segregation and o Secured by locks with restricted access clean up procedures; o Designed for access and regular cleaning by • Segregate waste with a high content of heavy metals (e.g. authorized cleaning staff and vehicles cadmium, thallium, arsenic, lead) to avoid entry into o Protected from sun, and inaccessible to animals / wastewater streams; rodents • Separate residual chemicals from containers and remove o Equipped with appropriate lighting and ventilation to proper disposal containers to reduce generation of o Segregated from food supplies and preparation areas contaminated wastewater. Different types of hazardous o Equipped with supplies of protective clothing, and chemicals should not be mixed; spare bags / containers • Establish procedures and mechanisms to provide for • Unless refrigerated storage is possible, storage times separate collection of urine, feces, blood, vomits, and other between generation and treatment of waste should not wastes from patients treated with genotoxic drugs. Such exceed the following: wastes are hazardous and should be treated accordingly o Temperate climate: 72 hours in winter, 48 hours in (see Table 1); summer • Aerosol cans and other gas containers should be o Warm climate: 48 hours during cool season, 24 hours segregated to avoid disposal via incineration and related during hot season explosion hazard; • Store mercury separately in sealed and impermeable • Segregate health care products containing PVC9 to avoid containers in a secure location; disposal via incineration (see Air Emissions below) or in • Store cytotoxic waste separately from other waste in a landfills. secure location; • Store radioactive waste in containers to limit dispersion, On-site Handling, Collection, Transport and Storage and secure behind lead shields. • Seal and replace waste bags and containers when they are approximately three quarters full. Full bags and containers Transport to External Facilities should be replaced immediately; • Transport waste destined for off-site facilities according to • Identify and label waste bags and containers properly prior the guidelines for transport of hazardous wastes / to removal (see Table 1); dangerous goods in the General EHS Guidelines ; • Transport waste to storage areas on designated trolleys / • Transport packaging for infectious waste should include an carts, which should be cleaned and disinfected regularly; inner, watertight layer of metal or plastic with a leak-proof • Waste storage areas should be located within the facility seal. Outer packaging should be of adequate strength and and sized to the quantities of waste generated, with the capacity for the specific type and volume of waste; following design considerations: • Packaging containers for sharps should be puncture-proof; o Hard, impermeable floor with drainage, and designed • Waste should be labeled appropriately, noting the for cleaning / disinfection with available water supply substance class, packaging symbol (e.g. infectious waste, 9 For examples of products containing PVC, see footnote 6. APRIL 30, 2007 4 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP radioactive waste), waste category, mass / volume, place Chemical disinfection involves the addition of chemicals to kill of origin within hospital, and final destination; pathogens in health care waste. Waste should be mechanically • Transport vehicles should be dedicated to waste and the shredded prior to treatment. Treatment involves the use and vehicle compartments carrying waste sealed. handling of hazardous chemicals, in addition to disposal of hazardous residues following treatment. Treatment and Disposal Options Facilities receiving hazardous health care waste should have all Wet thermal treatment disinfects waste by exposing shredded applicable permits and capacity to handle specific types of waste to high temperatures / pressure steam inside an exposure health care waste. Wastes from each category should be tank. Wastewater discharges and odor may result. Autoclaving treated according to the treatment methods and technologies is a type of wet thermal disinfection process typically used to described in Table 1. When selecting a waste disposal sterilize reusable medical equipment. Dry thermal disinfection technology, operators should consider other potential health and involves the shredding, heating, and compacting waste in a environmental issues that may be generated by the treatment. rotating auger. Air emissions and wastewater may be The main types of treatment and disposal technologies and generated, and residues require disposal. techniques available for health care waste are described below.10 Microwave irradiation involves the destruction of microorganisms through the microwave heating action of water Incineration is a high temperature dry oxidation process to contained within the waste. Following irradiation, waste is reduce organic, combustible waste to significantly smaller compacted and disposed of as part of the municipal waste quantities of inorganic, incombustible matter. Incineration may stream. Contaminated wastewater may also be generated. produce gaseous air emissions, ash residues, and wastewater. Depending on the amount of waste generated and the other Land disposal involves the disposal of health care waste into factors, HCFs may operate on-site incinerators, or waste may landfill facilities. Properly designed and operated sanitary be transported to an off-site incineration facility11. Incinerators landfills will protect against air and groundwater contamination. should have permits to accept health care waste and be Disposal of waste into open dumps is not considered good properly operated and maintained.12 Further guidance on practice and should be avoided. Pretreatment of waste prior to incineration is contained in the ‘Emissions to Air’ section, below. land disposal may involve encapsulation (filling containers with waste and an immobilizing material and sealing the containers). Inertization involves mixing waste with substances (e.g. 10 Further detail on waste management and disposal methods and technologies cement) to minimize leaching of toxic waste into ground or can be found in Pruess (1999), US EPA (2005b) Sector Notebook on Health surface water. care Facilities; and Health Care Without Harm (2007), For Proper Disposal: A Global Inventory of Alternative Medical Waste Technologies. 11 Further guidance on use of municipal incinerators for disposal of health care waste is addressed in Pruss (1999), page. 84. 12 Health care waste should be disposed of using pyrolytic or rotary kiln incinerators. Single chamber incinerators should only be used in emergency situations (e.g. acute outbreaks of communicable disease) when other incineration options for infectious waste are not available. APRIL 30, 2007 5 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP Emissions to Air hospital waste incinerator (HWI) should be carefully evaluated Sources of air emissions at HCFs may include exhaust air from against other technologies and techniques for waste heating, ventilation, and air conditioning (HVAC) systems, management and disposal discussed above15. Pollutants ventilation of medical gases and fugitive emissions released potentially emitted from HWIs include: from sources such as medical waste storage areas, medical • Heavy metals; technology areas, and isolation wards. Emissions may include • Organics in the flue gas, which can be present in the vapor exhaust from medical waste incineration if this waste phase or condensed or absorbed on fine particulates; management option is selected by the facility13. In addition, air • Various organic compounds (e.g. polychlorinated dibenzo- emissions may result from combustion related to power p-dioxins and furans [PCDD/Fs], chlorobenzenes, generation. Recommended prevention and control for power chloroethylenes, and polycyclic aromatic hydrocarbons generation combustion source emissions are addressed in the [PAHs]), which are generally present in hospital waste or General EHS Guidelines. can be generated during combustion and post-combustion processes; Exhaust air (e.g. from medical technology areas [MTAs], • Hydrogen chloride (HCl) and fluorides, and potentially other including isolation wards, laboratories, and waste storage and halogens-hydrides (e.g. bromine and iodine); treatment facilities) may be potentially contaminated with • Typical combustion products such as sulfur oxides (SOX), biological agents, pathogens, or other toxic materials, and nitrogen oxides (NOX), volatile organic compounds should be treated by conveying the exhaust air to combustion (including non-methane VOCs) and methane (CH4), carbon air to render it non-toxic and non-contagious before discharge. monoxide (CO), carbon dioxide (CO2), and nitrous oxide Condensate and blowdown liquids should be classified as health (N2O). care wastewater and treated accordingly (see ‘Wastewater’ below). A stack sufficiently tall to eliminate odor nuisances and Pollution prevention and control measures include: optimize dispersion should be used. Stack heights for all waste treatment facilities should be determined in accordance with • Application of waste segregation and selection including guidance provided in the General EHS Guidelines. removal of the following items from waste destined for incineration: halogenated plastics (e.g. PVC), pressurized gas containers, large amounts of active chemical waste, Incineration silver salts and photographic / radiographic waste, waste Large general hospitals may be equipped with their own with high heavy metal content (e.g. broken thermometers, incinerator plant, which is the major source of emissions to air batteries), and sealed ampoules or ampoules containing and wastewater. Typically, only a relatively small portion of heavy metals; medical waste should be incinerated14, and the need for a 13 Controlled-air incineration (also referred to as pyrolytic, starved-air, two-stage purpose. The types of waste incinerated typically include a heterogeneous mix incineration, or modular combustion) is the most widely used HWI technology. of some, or all, of the following: human and animal infected anatomical waste; Single-chamber and drum / brick incinerators should be used only as a last absorbents; alcohol, disinfectants; glass; fecal matter; gauze, pads, swabs, resort option. garments, paper, and cellulose; plastics, PVC, and syringes; sharps and 14 Infectious and pathological waste, selected pharmaceuticals (combustibility to needles; and fluids and residuals. be determined from the manufacturer’s specifications) and chemicals, and 15 Non-incineration Medical Waste Treatment Technologies in Europe, Health sharps may be combusted in a pyrolytic incineration facility designed for this Care Without Harm (2004). APRIL 30, 2007 6 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP Table 1. Treatment and disposal methods for categories of health care waste Type of waste Summary of treatment and disposal options / notes Infectious waste: Includes waste suspected to contain pathogens (e.g. Waste Segregation Strategy: Yellow or red colored bag / container, marked “infectious” with international infectious symbol. Strong, leak proof plastic bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity bag, or container capable of being autoclaved. to cause disease in susceptible hosts. Includes pathological and anatomical material (e.g. tissues, organs, body parts, human fetuses, Treatment : Chemical disinfection; Wet thermal treatment; Microwave irradiation; Safe burial on hospital premises; Sanitary landfill; Incineration (Rotary animal carcasses, blood, and other body fluids), clothes, dressings, kiln; pyrolytic incinerator; single-chamber incinerator; drum or brick incinerator) e equipment / instruments, and other items that may have come into • Highly infectious waste, such as cultures from lab work, should be sterilized using wet thermal treatment, such as autoclaving. contact with infectious materials. • Anatomical waste should be treated using Incineration (Rotary kiln; pyrolytic incinerator; single-chamber incinerator; drum or brick incineratore). Sharps: Includes needles, scalpels, blades, knives, infusion sets, saws, Waste Segregation Strategy: Yellow or red color code, marked “Sharps”. Rigid, impermeable, puncture-proof container (e.g. steel or hard plastic) with broken glass, and nails etc. cover. Sharps containers should be placed in a sealed, yellow bag labeled “infectious waste”. Treatment : Chemical disinfection; Wet thermal treatment; Microwave irradiation; Encapsulation; Safe burial on hospital premises; Incineration (Rotary kiln; pyrolytic incinerator; single-chamber incinerator; drum or brick incinerator) e • Following incineration, residues should be landfilled. • Sharps disinfected with chlorinated solutions should not be incinerated due to risk of generating POPs. • Needles and syringes should undergo mechanical mutilation (e.g. milling or crushing) prior to wet thermal treatment Pharmaceutical waste: Includes expired, unused, spoiled, and Waste Segregation Strategy: Brown bag / container. Leak-proof plastic bag or container. contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer needed, including containers and other potentially Treatment : Sanitary landfillª; Encapsulationª; Discharge to sewer ª; Return expired drugs to supplier; Incineration (Rotary kiln; pyrolytic incinerator ª); contaminated materials (e.g. drug bottles vials, tubing etc.). Safe burial on hospital premisesª as a last resort. • Small quantities: Landfill disposal acceptable, however cytotoxic and narcotic drugs should not be landfilled. Discharge to sewer only for mild, liquid pharmaceuticals, not antibiotics or cytotoxic drugs, and into a large water flow. Incineration acceptable in pyrolytic or rotary kiln incinerators, provided pharmaceuticals do not exceed 1 percent of total waste to avoid hazardous air emissions. Intravenous fluids (e.g. salts, amino acids) should be landfilled or discharged to sewer. Ampoules should be crushed and disposed of with sharps. • Large quantities: Incineration at temperatures exceeding 1200 °C. Encapsulation in metal drums. Landfilling not recommended unless encapsulated in metal drums and groundwater contamination risk is minimal. Genotoxic / cytotoxic waste: Genotoxic waste may have mutagenic, Waste Segregation Strategy: See above for “infectious waste”. Cytotoxic waste should be labeled “Cytotoxic waste”. teratogenic, or carcinogenic properties, and typically arises from the feces, urine, and vomit of patients receiving cytostatic drugs, and from Treatment : Return expired drugs to supplier; Chemical degradation; Encapsulationª; Inertization; Incineration (Rotary kiln, pyrolytic incinerator); treatment with chemicals and radioactive materials. Cytotoxic drugs are • Cytotoxic waste should not be landfilled or discharged to sewer systems. commonly used in oncology and radiology departments as part of cancer • Incineration is preferred disposal option. Waste should be returned to supplier where incineration is not an option. Incineration should be treatments. undertaken at specific temperatures and time specifications for particular drugs. Most municipal or single chamber incinerators are not adequate for cytotoxic waste disposal. Open burning of waste is not acceptable. • Chemical degradation may be used for certain cytotoxic drugs – See Pruss et al. (1999) Annex 2 for details. • Encapsulation and inertization should be a last resort waste disposal option. APRIL 30, 2007 7 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP Table 1. Treatment and disposal methods for categories of health care waste Type of waste Summary of treatment and disposal options / notes Chemical waste: Waste may be hazardous depending on the toxic, Waste Segregation Strategy: Brown bag / container. Leak-proof plastic bag or container resistant to chemical corrosion effects. corrosive, flammable, reactive, and genotoxic properties. Chemical waste may be in solid, liquid, or gaseous form and is generated through use of Treatment: Return unused chemicals to supplier; Encapsulationª; Safe burial on hospital premisesª; Incineration (Pyrolytic incineratorª; chemicals during diagnostic / experimental work, cleaning, housekeeping, and disinfection. Chemicals typically include formaldehyde, photographic • Facilities should have permits for disposal of general chemical waste (e.g. sugars, amino acids, salts) to sewer systems. chemicals, halogenated and nonhalogenated solvents d, organic • Small hazardous quantities: Pyrolytic incineration, encapsulation, or landfilling. chemicals for cleaning / disinfecting, and various inorganic chemicals • Large hazardous quantities: Transported to appropriate facilities for disposal, or returned to the original supplier using shipping arrangements that (e.g. acids and alkalis). abide by the Basel Convention. Large quantities of chemical waste should not be encapsulated or landfilled. Radioactive waste: Includes solid, liquid, and gaseous materials that Waste Segregation Strategy: Lead box, labeled with the radioactive symbol. have been contaminated with radionuclides. Radioactive waste originates from activities such as organ imaging, tumor localization, radiotherapy, Treatment : Radioactive waste should be managed according to national requirements and current guidelines from the International Atomic Energy and research / clinical laboratory procedures, among others, and may Agency. IAEA (2003). Management of Waste from the Use of Radioactive Materials in Medicine, Industry and Research. IAEA Draft Safety Guide DS include glassware, syringes, solutions, and excreta from treated patients. 160, 7 February 2003. Waste with high content of heavy metals: Batteries, broken Waste Segregation Strategy: Waste containing heavy metals should be separated from general health care waste. thermometers, blood pressure gauges, (e.g. mercury and cadmium content). Treatment : Safe storage site designed for final disposal of hazardous waste. • Waste should not be burned, incinerated, or landfilled. Transport to specialized facilities for metal recovery. Pressurized containers: Includes containers / cartridges / cylinders for Waste Segregation Strategy: Pressurized containers should be separated from general health care waste. nitrous oxide, ethylene oxide, oxygen, nitrogen, carbon dioxide, compressed air and other gases. Treatment : Recycling and reuse; Crushing followed by landfill • Incineration is not an option due to explosion risks • Halogenated agents in liquid form should be disposed of as chemical waste, as above. General health care waste (including food waste and paper, plastics, Waste Segregation Strategy: Black bag / container. Halogenated plastics such as PVC should be separated from general health care facility waste to cardboard): avoid disposal through incineration and associated hazardous air emissions from exhaust gases (e.g. hydrochloric acids and dioxins). Treatment: Disposal as part of domestic waste. Food waste should be segregated and composted. Component wastes (e.g. paper, cardboard, recyclable plastics [PET, PE, PP], glass) should be segregated and sent for recycling. Source : Safe Management of Wastes from Health-Care Activities. International Labor Organization (ILO), Eds. Pruss, A. Giroult, and P. Rushbrook (1999) Notes: a. Small quantities only b. Low-level infectious waste only c. Low-level liquid waste only d. Halogenated and nonhalogenated solvents (e.g. chloroform, TCE, acetone, methanol) are usually a laboratory-related waste stream for fixation and preservation of specimens in histology / pathology and for extractions in labs. e. Note on incinerators. Pyrolytic and rotary kiln incinerators should be used. Use of single-chamber and drum / brick incinerators are not normally considered good practice, except in emergency situations as a last option. APRIL 30, 2007 8 Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP • Incinerators should have permits issued by authorized venturi scrubbers are also used to control heavy metal regulatory agencies and be operated and maintained by emissions. The volatile heavy metals usually condense to trained employees to ensure proper combustion form a fume (less than 2 µm) that is only partially collected temperature, time, and turbulence specifications necessary by pollution control equipment; for adequate combustion of waste.16 This includes • Management of incineration residues such as fly ash, implementation of operational controls including bottom ash and liquid effluents from flue gas cleaning as a combustion and flue gas outlet temperatures (combustion hazardous waste (see General EHS Guidelines) as they temperatures should be above 850 °C while flue gases may contain high concentrations of POPs. need to be quenched very quickly to avoid formation and reformation of POPs) as well as use of flue gas cleaning Wastewater devices meeting international standards.17 Process Wastewater Secondary air pollution control measures for hospital waste Wastewater from HCFs often has a quality similar to urban incinerators include the following: wastewater. Contaminated wastewater may result from discharges from medical wards and operating theaters (e.g. • Wet scrubbers to control acid gas emissions (e.g. body fluids and excreta, anatomical waste), laboratories (e.g. hydrochloric acid [HCl)], sulfur dioxide [SO2, and fluoride microbiological cultures, stocks of infectious agents), compounds]). A caustic scrubbing solution will increase the pharmaceutical and chemical stores; cleaning activities (e.g. efficiency for SO2 control; waste storage rooms), and x-ray development facilities. • Control of particulate matter may be achieved through use Wastewater may also result from treatment disposal of cyclones, fabric filters, and / or electrostatic precipitators technologies and techniques, including autoclaving, microwave (ESP). Efficiencies depend on the particle size distribution irradiation, chemical disinfection, and incineration (e.g. of the particulate matter from the combustion chamber. treatment of flue gas using wet scrubbers which may contain Particulate matter from hospital incinerators is commonly suspended solids, mercury, other heavy metals, chlorides, and between 1.0 to 10 micrometers (µm). ESPs are generally sulfates). less efficient than baghouses in controlling fine particulates and metals from HWI; Depending on the effectiveness of hazardous waste • Control of volatile heavy metals depends on the management practices (in particular waste segregation temperature at which the control device operates. Fabric strategies described above), hazardous health care wastes may filters and ESP typically operate at relatively high enter the wastewater stream, including microbiological temperatures and may be less effective than those that pathogens (wastewater with a high content of enteric operate at lower temperatures. Venturi quenches and pathogens, including bacteria, viruses, and helminthes / parasitic worms), hazardous chemicals, pharmaceuticals, and 16 Technical information on the proper operation and maintenance of hospital radioactive isotopes. Pollution prevention measures to minimize waste incinerators may be obtained from WHO (1999) Chapter 8 and the US EPA Handbook on the Operation and Maintenance of Medical Waste the generation of wastewater include the following: Incinerators (2002). 17 Refer to Guidelines on BAT/BEP practices relevant to Article 5 and Annex C of the Stockholm Convention on Persistent Organic Pollutants, Section V. APRIL 30, 2007 9 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP • Waste segregation measures should be employed to sedimentation for suspended solids reduction using clarifiers; minimize entry of solid waste into the wastewaster stream, biological treatment, typically aerobic treatment, for reduction of including: soluble organic matter (BOD); biological or chemical nutrient o Procedures and mechanisms for separate collection of removal for reduction in nitrogen and phosphorus; chlorination urine, feces, blood, and vomit from patients treated of effluent when disinfection is required; dewatering and with genotoxic drugs to avoid their entry into the disposal of residuals as hazardous medical / infectious waste. wastewater stream (as described above under waste Additional engineering controls may be required for (i) removal segregation for hazardous and other wastes); of active ingredients (antibiotics and miscellaneous o Collection of large quantities of pharmaceuticals for pharmaceutical products, among other hazardous constituents), separate treatment or return to manufacturer (see and (ii) containment and treatment of volatile constituents and Table 1). Small quantities of mild, liquid aerosols stripped from various unit operations in the wastewater pharmaceuticals, excluding antibiotics or cytotoxic treatment system. drugs, may be discharged to sewer systems with a Wastewater generated from use of wet scrubbers to treat air large water flow. emissions should be treated through chemical neutralization, flocculation, and sludge settling. Sludge should be considered Municipal Wastewater Treatment 18 hazardous, and may be treated off-site in a hazardous waste If wastewater is discharged to sanitary sewage treatment facility, or encapsulated in drums with mortar and landfilled. systems, the HCF should ensure that wastewater characteristics Sludge treatment should include anaerobic digestion to ensure are in compliance with all applicable permits, and that the destruction of helminthes and pathogens. Alternatively, it can be municipal facility is capable of handling the type of effluent dried in drying beds before incineration with solid infectious discharged, as discussed in the General EHS Guidelines. wastes. On-site Wastewater Treatment Other Wastewater Streams & Water Consumption In cases where wastewater is not discharged to sanitary sewage Guidance on the management of non-contaminated wastewater systems, HCF operators should ensure that wastewater from utility operations, non-contaminated stormwater, and receives on-site primary and secondary treatment, in addition to sanitary sewage is provided in the General EHS Guidelines. chlorine disinfection. Contaminated streams should be routed to the treatment system for industrial process wastewater. Recommendations to reduce Techniques for treating wastewater in this sector include source water consumption, especially where it may be a limited natural segregation and pretreatment for removal / recovery of specific resource, are provided in the General EHS Guidelines. contaminants such as radio isotopes, mercury, etc.; skimmers or oil water separators for separation of floatable solids; filtration for separation of filterable solids; flow and load equalization; 1.2 Occupational Health and Safety 18 Additional criteria for disposal to municipal systems may be found in WHO Occupational health and safety impacts during the construction (1999). and decommissioning of health care facilities (HCF) are APRIL 30, 2007 10 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP common to those of most civil construction facilities and their • Formulate an exposure control plan for blood-borne prevention and control is discussed in the General EHS pathogens;20 Guidelines. General health and safety hazards occurring in • Provide staff members and visitors with information on HCFs include manual handling injuries, such as sprains and infection control policies and procedures;21 strains from lifting and carrying patients; falls, trips, and slips; • Establish Universal / Standard Precautions22 to treat all injuries caused by moving objects; and mental stress. These blood and other potentially infectious materials with and other typical physical hazards are discussed in the General appropriate precautions, including: EHS Guidelines. o Immunization for staff members as necessary (e.g. vaccination for hepatitis B virus) HCF health and safety hazards may affect health care o Use of gloves23, masks, and gowns providers, cleaning and maintenance personnel, and workers o Adequate facilities for hand washing24. Hand washing involved in waste management handling, treatment, and is the single most important procedure for preventing disposal. Industry specific hazards include the following: infections (e.g. nosocomial and community). Hand washing should involve use of soap / detergent, • Exposure to infections and diseases rubbing to cause friction, and placing hands under • Exposure to hazardous materials / waste running water. Washings of hands should be • Exposure to radiation undertaken before and after direct patient contacts • Fire safety and contact with patient blood, body fluids, secretions, excretions, or contact with equipment or articles Exposure to Infections / Diseases contaminated by patients. Washing of hands should Health care providers and personnel may be exposed to general also be undertaken before and after work shifts; infections, blood-borne pathogens, and other potential infectious eating; smoking; use of personal protective equipment materials (OPIM)19 during care and treatment, as well as during (PPE); and use of bathrooms. If hand washing is not collection, handling, treatment, and disposal of health care possible, appropriate antiseptic hand cleanser and waste. clean cloths / antiseptic towelettes should be provided. Hands should then be washed with soap and running The following measures are recommended to reduce the risk of water as soon as practical transferring infectious diseases to health care providers: 20 U.S. Department of Labor Occupational Health and Safety Administration (OSHA). Regulations (Standards - 29 CFR) Bloodborne pathogens. - 1910.1030 19 According to US OSHA, blood-borne pathogens are pathogenic for health care facilities. microorganisms that are present in human blood and can cause disease in 21 U.S. Centers for Disease Control (CDC), Guideline for infection control in humans, including human immunodeficiency virus (HIV), hepatitis B virus (HIB), health care personnel (1998) , Available at: and hepatitis C virus (HCV). Other potentially infectious materials (OPIM) refers http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf to (1) The following human body fluids: semen, vaginal secretions, cerebrospinal 22 Transmission-based precautions include air, droplet, and contact precautions fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, are available from the US Occupational Health and Safety Administration saliva in dental procedures, any body fluid that is visibly contaminated with (OSHA) at http://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html blood, and all body fluids in situations where it is difficult or impossible to 23 Health care workers may be latex sensitive, resulting in serious allergic differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue reactions. Hypoallergenic gloves, glove liners, powderless gloves, or other cultures, organ cultures, and HIV- or HBV-containing culture medium or other similar alternatives should be available to those workers who are allergic. solutions; and blood, organs, or other tissues from experimental animals 24 US CDC Guideline for Hand-Washing in Health Care Facilities (2002). infected with HIV or HBV. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm APRIL 30, 2007 11 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP o Procedures and facilities for handling dirty linen and • Implement immunization for staff members, as necessary contaminated clothing, and preparing and handling (e.g. vaccination for hepatitis B virus, tetanus food immunization); o Appropriate cleaning and waste disposal practices for • Provide adequate supplies of PPE for personnel involved in the health care workplace waste management including: overalls / industrial aprons, • The following recommendations should be implemented leg protectors, boots, heavy duty gloves, helmets, visors / when using and handling of needles / sharps: face masks and eye protection (especially for cleaning of o Use safer needle devices and needleless devices to hazardous spills), and respirators (for spills or waste decrease needlestick or other sharps exposures25 involving toxic dust or incinerator residue) as necessary; o Do not bend, recap, or remove contaminated needles • Provide washing facilities for personal hygiene, particularly and other sharps unless such an act is required by a at waste storage locations. specific procedure or has no feasible alternative o Do not shear or break contaminated sharps Exposure to Hazardous Materials and Waste o Have needle containers available near areas where HCF workers may be exposed to hazardous materials and needles may be found wastes, including glutaraldehyde (toxic chemical used to o Discard contaminated sharps immediately or as soon sterilize heat sensitive medical equipment), ethylene oxide gas as feasible into appropriate containers (a sterilant for medical equipment), formaldehyde, mercury o Used disposable razors should be considered (exposure from broken thermometers), chemotherapy and contaminated waste and disposed of in appropriate antineoplastic chemicals, solvents, and photographic chemicals, sharps containers among others. In addition to the guidance provided above, • Establish policies to exclude animals from facility property. hazardous materials and wastes should be handled according to occupational health and safety guidance provided in the In addition to the above recommendations, the following General EHS Guidelines. measures are applicable to personnel involved in waste management to reduce the risk of transferring infectious diseases: Waste Anesthetic Gas (WAG) Exposure Health care workers may be at risk of toxic exposure to nitrous oxide; the halogenated agents halothane (fluothane), enflurane (ethrane), isoflurane (forane); and other substances typically 25 OSHA recommends the following safety devices: Needleless connector used as inhalation anesthetics. systems: needleless connectors for IV delivery systems (e.g. blunt cannula for use with prepierced ports and valved connectors that accept tapered or luer ends of IV tubing). Self-Sheathing Safety Feature: Sliding needle shields Recommended measures to control exposure to waste attached to disposable syringes and vacuum tube holders (e.g. disposable scalpels with safety features such as a sliding blade shield). Retractable anesthetic gas (WAG used in the operating room for example) Technology: Needles or sharps that retract into a syringe, vacuum tube holder, or back into the device (e.g. syringe with a retractable needle, retractable finger / include use of a scavenging unit attached to the anesthesia unit. heel-stick lancets). Self Blunting Technology: Self-blunting phlebotomy and winged-steel "butterfly" needles (a blunt cannula seated inside the phlebotomy The scavenging unit may have a charcoal filter that absorbs needle is advanced beyond the needle tip before the needle is withdrawn from the vein). Add-on Safety Feature: Hinged or sliding shields attached to halogenated anesthetic gases, but not nitrous oxide. Spent phlebotomy needles, winged steel needles, and blood gas needles. charcoal filters should be disposed of as hazardous waste. If APRIL 30, 2007 12 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP there is no scavenging unit, or if the scavenging unit does not information (this information should be displayed in obvious have a filter, vacuum lines are used to collect WAGs which are locations and clearly written in relevant languages). subsequently vented outside and dispersed. 1.3 Community Health and Safety Radiation Community health and safety issues during the construction, Occupational radiation exposure may result from equipment operations, and decommissioning of HCFs are generally emitting X-rays and gamma rays (e.g. CT scanners), common to those of most industrial facilities, and are discussed radiotherapy machines, and equipment for nuclear medicine in the General EHS Guidelines. Community hazards activities. HCF operators should develop a comprehensive plan associated with health care facility environments, particularly to control radiation exposure in consultation with the affected related to hazardous health care waste, necessitate that workforce. This plan should be refined and revised as soon as members of the public receive adequate information regarding practicable on the basis of assessments of actual radiation potential infection hazards within the facility, and at associated exposure conditions, and radiation control measures should be waste disposal sites (e.g. landfills). Guidance on community designed and implemented accordingly. Recommendations to disease transmission is provided in the General EHS prevent and control exposure to radiation are discussed in the Guidelines . General EHS Guidelines. Fire Safety 2.0 Performance Indicators and The risk of fire in health care facilities is significant due to the Industry Benchmarks storage, handling, and presence of chemicals, pressurized gases, boards, plastics, and other flammable substrates. Fire 2.1 Environmental Performance safety recommendations applicable to occupational areas are Emissions and Effluent Guidelines presented under ‘Occupational Health and Safety’ in the Tables 2 and 3 present emission and effluent guidelines for this General EHS Guidelines. Recommendations applicable to sector. Guideline values for process emissions and effluents in buildings accessible to the public, including health care facilities, this sector are indicative of good international industry practice are presented under ‘Life and Fire Safety’ in the General EHS as reflected in relevant standards of countries with recognized Guidelines . Additional recommendations for fire safety include: regulatory frameworks. These guidelines are achievable under • Installation of smoke alarms and sprinkler systems; normal operating conditions in appropriately designed and • Maintenance of all fire safety systems in proper working operated facilities through the application of pollution prevention order, including self-closing doors in escape routes and and control techniques discussed in the preceding sections of ventilation ducts with fire safety flaps; this document. Emissions guidelines are applicable to process • Training of staff for operation of fire extinguishers and emissions. Combustion source emissions guidelines associated evacuation procedures; with steam- and power-generation activities from sources with a capacity equal to or lower than 50 megawatt thermals (MWth) • Development of facility fire prevention or emergency are addressed in the General EHS Guidelines with larger response and evacuation plans with adequate guest APRIL 30, 2007 13 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP power source emissions addressed in the EHS Guidelines for Table 3. Air Emission Levels for Hospital Waste Thermal Power. Guidance on ambient considerations based on Incineration Facilitiesb the total load of emissions is provided in the General EHS Pollutants Units Guideline Value Guidelines . Total Particulate matter (PM) mg/Nm3 10 Effluent guidelines are applicable for direct discharges of treated Total organic carbon (TOC) mg/Nm3 10 effluents to surface waters for general use. Site-specific Hydrogen Chloride (HCl) mg/Nm3 10 discharge levels may be established based on the availability Hydrogen Fluoride (HF) mg/Nm3 1 and conditions in the use of publicly operated sewage collection Sulfur dioxide (SO2) mg/Nm3 50 and treatment systems or, if discharged directly to surface waters, on the receiving water use classification as described in Carbon Monoxide (CO) mg/Nm3 50 the General EHS Guidelines. These levels should be achieved, NOX mg/Nm3 200-400 (a) without dilution, at least 95 percent of the time that the plant or Mercury (Hg) mg/Nm3 0.05 unit is operating, to be calculated as a proportion of annual Cadmium + Thallium mg/Nm3 0.05 operating hours. Deviation from these levels in consideration of (Cd + Tl) Sb, As, Pb, Cr, Co, Cu, Mn, Ni specific, local project conditions should be justified in the mg/Nm3 0.5 and V Polychlorinated dibenzodioxin environmental assessment. ng/Nm3TEQ 0.1 and dibenzofuran (PCDD/F) Notes: a. 200 mg/m3 for new plants or for existing incinerators with a nominal capacity Table 2. Effluent Levels for Health Care Facilities exceeding 6 tonnes per hour; 400 mg/m3 for existing incinerators with a nominal capacity of 6 tonnes per hour or less b. Oxygen level for incinerators is 7 percent. Pollutants Units Guideline Value pH S.U 6-9 Biochemical oxygen demand mg/L 50 (BOD5) Environmental Monitoring Chemical oxygen demand mg/L 250 (COD) Environmental monitoring programs for this sector should be Oil and grease mg/L 10 implemented to address all activities that have been identified to Total suspended solid (TSS) mg/L 50 Cadmium (Cd) mg/L 0.05 have potentially significant impacts on the environment, during Chromium (Cr) mg/L 0.5 Lead (Pb) mg/L 0.1 normal operations and upset conditions. Environmental Mercury (Hg) mg/L 0.01 monitoring activities should be based on direct or indirect Chlorine, total residual mg/L 0.2 Phenols mg/L 0.5 indicators of emissions, effluents, and resource use applicable Total coliform bateria MPNa / 100ml 400 to the particular project. Monitoring frequency should be Polychlorinated dibenzodioxin and Ng/L 0.1 sufficient to provide representative data for the parameter being dibenzofuran (PCDD/F) monitored. Monitoring should be conducted by trained Temperature increase °C <3b individuals following monitoring and record-keeping procedures Notes: a MPN = Most Probable Number and using properly calibrated and maintained equipment. b At the edge of a scientifically established mixing zone which takes into account ambient water quality, receiving water use, potential receptors and Monitoring data should be analyzed and reviewed at regular assimilative capacity intervals and compared with the operating standards so that any necessary corrective actions can be taken. Additional guidance APRIL 30, 2007 14 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP on applicable sampling and analytical methods for emissions published by European Union member states,30 or other similar and effluents is provided in the General EHS Guidelines . sources. Resource Consumption, Energy Use, and Waste Accident and Fatality Rates Generation Projects should try to reduce the number of accidents among Environmental performance of hospital installations should also project workers (whether directly employed or subcontracted) to be evaluated against internationally published benchmarks for a rate of zero, especially accidents that could result in lost work resource consumption, energy use and waste generation. If time, different levels of disability, or even fatalities. Facility rates inefficiencies are identified, the comparison with published may be benchmarked against the performance of facilities in this benchmarks should be followed by a detailed audit or survey to sector in developed countries through consultation with identify potential opportunities for improvement, without published sources (e.g. US Bureau of Labor Statistics and UK compromising the objective of providing quality, safe, health Health and Safety Executive)31. care.26 Occupational Health and Safety Monitoring 2.2 Occupational Health and Safety The working environment should be monitored for occupational hazards relevant to the specific project. Monitoring should be Occupational Health and Safety Guidelines designed and implemented by accredited professionals32 as part Occupational health and safety performance should be of an occupational health and safety monitoring program. evaluated against internationally published exposure guidelines, Facilities should also maintain a record of occupational of which examples include the Threshold Limit Value (TLV®) accidents and diseases and dangerous occurrences and occupational exposure guidelines and Biological Exposure accidents. Additional guidance on occupational health and Indices (BEIs®) published by American Conference of safety monitoring programs is provided in the General EHS Governmental Industrial Hygienists (ACGIH),27 the Pocket Guide Guidelines . to Chemical Hazards published by the United States National Institute for Occupational Health and Safety (NIOSH), 28 Permissible Exposure Limits (PELs) published by the Occupational Safety and Health Administration of the United States (OSHA),29 Indicative Occupational Exposure Limit Values 26 Examples of reference sources include: Energy Consumption: United States Department of Energy, Energy Information Administration (http://www.eia.doe.gov/); Natural Resource Canada, Office of Energy Efficiency (http://oee.nrcan.gc.ca); Water Use: Healthcare Environmental Resource Center (http://www.hercenter.org/); Waste Generation: Hospitals for a Health Environment (http://www.h2e-online.org/) 30 Available at: http://europe.osha.eu.int/good_practice/risks/ds/oel/ 27 Available at: http://www.acgih.org/TLV/ and http://www.acgih.org/store/ 31 Available at: http://www.bls.gov/iif/ and 28 Available at: http://www.cdc.gov/niosh/npg/ http://www.hse.gov.uk/statistics/index.htm 29 Available at: 32 Accredited professionals may include Certified Industrial Hygienists, http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDAR Registered Occupational Hygienists, or Certified Safety Professionals or their DS&p_id=9992 equivalent. APRIL 30, 2007 15 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP 3.0 References and Additional Sources American Institute of Architects (AIA). 2001. Guidelines for Design and US CDC/NIOSH. 2002. Compendium of NIOSH Health Care Worker Research Construction of Hospital and Health Care Facilities. Washington, DC: AIA. 2001. Publication No. 2003-108. Cincinnati, OH: CDC/NIOSH. Available at Available at http://www.aia.org/ http://www.cdc.gov/niosh/topics/healthcare/ American Society for Healthcare Engineering (ASHE) of the American Hospital US CDC/NIOSH. 1988. Guidelines for Protecting the Safety and Health of Association (AHA). http://www.ashe.org Health Care Workers. Cincinnati, OH: CDC/NIOSH. Available at http://www.cdc.gov/niosh/hcwold0.html Australian Government, National Occupational Health and Safety Commission (NOHSC, now Australian Compensation and Safety Council (ASCC)). 2004. US CDC/NIOSH. Health Care Workers. Cincinnati, OH: NIOSH. Available at Health and Community Services. Canberra: ASCC. http://www.cdc.gov/niosh/topics/healthcare/ Environment Australia. 1999. National Pollutant Inventory. National Industry United States Department of Energy, Energy Information Administration, Energy Handbook for Hospitals. Canberra: Environment Australia. Available at Consumption in Health Care Facilities (http://www.eia.doe.gov/) http://www.npi.gov.au/handbooks/approved_handbooks/pubs/hospitals.pdf US Department of Labor, Occupational Safety and Health Administration European Commission (EC). 2005. European Integrated Pollution Prevention (OSHA). 1991. Waste Anesthetic Gases. Fact Sheet No. OSHA 91-38. and Control Bureau (EIPPCB). BAT Techniques Reference (BREF) on Waste Washington, DC: OSHA. Available at http://www.osha.gov Incineration. Seville: EIPPCB. Available at http://eippcb.jrc.es/pages/FActivities.htm US Department of Labor, OSHA. Hospital e-tool. Available at http://www.osha.gov/SLTC/etools/hospital/index.html European Environment Agency (EEA) . 2002. EMEP/CORINAIR Emission Inventory Guidebook. Group 9: Waste Treatment and Disposal. Incineration of US Department of Labor OSHA. Regulations (Standards - 29 CFR) Hospital Wastes, Activity 090207. Emission Inventory Guidebook. Copenhagen: Bloodborne pathogens. - 1910.1030. Washington, DC: OSHA. Available at EEA. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDAR DS&p_id=10051 Green Guide for Health Care (http://www.gghc.org) US Environmental Protection Agency (EPA). 2000. 40 CFR Part 62. Approval Health Care Without Harm. 2001. Non-Incineration Medical Waste Treatment and Promulgation of State Plans for Designated Facilities and Pollutants. Technologies. Washington, DC: Health Care Without Harm. Available at Subpart HHH: Federal Plan Requirements for Hospital/Medical/Infectious Waste http://www.noharm.org/ Incinerators Constructed on or before June 20, 1996, Final Rule. Washington, DC: EPA. Available at http://www.epa.gov/ttn/atw/129/hmiwi/rihmiwi.html Health Care Without Harm. 2007. For proper disposal: A global inventory of alternative medical waste treatment technologies.Washington, DC: Health Care US EPA. 1997. 40 CFR Part 60. Standards of Performance for New Stationary Without Harm. Available at Sources and Emission Guidelines for Existing Sources. Subparts Ec and Ce: http://www.noharm.org/details.cfm?ID=1514&type=document Hospital/Medical/Infectious Waste Incinerators, Final Rule. Washington, DC: EPA. Available at http://www.epa.gov/ttn/atw/129/hmiwi/rihmiwi.html Healthcare Environmental Resource Center (http://www.hercenter.org/) US EPA. 2002. Handbook on the Operation and Maintenance of Medical Waste Hospitals for a Healthy Environment (http://www.h2e-online.org/) Incinerators. EPA/625/6-89/024. Washington, DC: EPA. International Atomic Energy Association (IAEA). 2003. Management of Waste US EPA. 2005a. Office of Research and Development, National Risk from the Use of Radioactive Materials in Medicine, Industry and Research. IAEA Management Research Laboratory. Health Care Guide to Pollution Prevention Draft Safety Guide DS 160, February 7. Vienna: IAEA. Implementation through Environmental Management Systems. EPA/625/C- 05/003. Washington, DC: EPA. Available at International Labor Organization (ILO). 1987. ILO Code of Practice. Radiation http://www.epa.gov/nrmrl/pubs/625c05003/625c05003.htm Protection of Workers (Ionising Radiations). Geneva: ILO. Available at http://www.ilo.org/public/english/protection/safework/ US EPA. 2005b. EPA Office of Compliance Sector Notebook Project. Profile of the Healthcare Industry. EPA/310-R-05-002. Washington, DC: EPA. Available at Natural Resource Canada, Office of Energy Efficiency, Energy Consumption in http://epa.gov/compliance/resources/publications/assistance/sectors/notebooks/ Health Care Facilities (http://oee.nrcan.gc.ca) health.pdf United States (US) Centers for Disease Control and Prevention (CDC). 2002. Government of Western Australia, Department of Consumer and Employment Guideline for Hand-Washing in Health Care Facilities. Recommendations of the Protection, WorkSafe. 2003. Reducing the Risk of Infectious Diseases in Child Healthcare Infection Control Practices Advisory Committee and the Care Workplaces. West Perth, WA: Worksafe. Available at HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Prepared by Boyce, J. http://www.worksafe.wa.gov.au and D. Pittet. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm World Health Organization (WHO). 2004. Safe Health-care Waste Management. Policy Paper. Geneva: WHO. Available at US CDC, National Center for Infectious Diseases (NIOD). 1998. Guideline for http://www.who.int/water_sanitation_health/medicalwaste/en/hcwmpolicye.pdf infection control in health care personnel, 1998. Atlanta, GA: NIOD. Available at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf WHO. 1999. Safe Management of Wastes from Healthcare Activities. Eds. Pruss, A. Giroult, and P. Rushbrook. Geneva: WHO. Available at US CDC. National Institute for Occupational Safety and Health (NIOSH). 2004. http://www.who.int/water_sanitation_health/medicalwaste/wastemanag/en/ Worker Health Chartbook 2004. NIOSH Publication No. 2004-146. Cincinnati, OH: CDC/NIOSH. Available at http://www.cdc.gov/niosh/docs/chartbook/ WHO. 2005. Mercury in Health Care. Policy Paper. Geneva: WHO. Available at: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf APRIL 30, 2007 16 FINAL DOCUMENT Environmental, Health, and Safety Guidelines HEALTH CARE FACILITIES WORLD BANK GROUP Annex A: General Description of Industry Activities The Health Care Facilities (HCF) sector includes a diverse 500,000 per bed in developed countries, and in developing range of facilities and activities involving general hospitals, small countries may range from US$175,000- 200,000 per bed. inpatient primary care hospitals, outpatient facilities, assisted As part of day-to-day operations, HCFs generate a variety of living facilities, and hospice facilities. Ancillary facilities may include medical laboratories and research facilities, mortuary wastes, including air emissions, wastewater effluents, health care waste (e.g. infectious, pathologic, and chemical wastes), centers, and blood banks and collection services. and municipal solid waste. Average electricity consumption for The HCF sector involves close contact among patients, health an HCF is influenced by its design criteria, particularly by the care providers, and support staff; extensive use of sharps and availability or need for specific services. These may include a instruments designed for diagnostic and curative (invasive and dedicated heating plant or in-house services such as kitchens noninvasive) procedures; and utilization of pharmaceutical, and laundries, which may require outsourcing if unavailable in chemical, radiological, and other agents for diagnosis, the HCF. The energy consumption of a general hospital is treatment, cleaning, and disinfection. almost double that consumed by all other types of buildings, mostly because of MTA energy needs. The basic infrastructure elements / activities of HCF facilities are to improve the health of patients, prevent transmission of Figure A.1: Schematic Diagram of a infections among patients and staff, and control impacts to Health Care Facility environment, health, and safety including maintenance of sanitary conditions; use of appropriate disinfection and Areas dedicated to patients and services (P&SA) Include mainly: outpatient facilities, inpatient wards, sterilization techniques; provision of potable water and clean air administration and general store for all operations; and nosocomial infection control. Medical technology area (MTA) Include mainly: surgery and critical care, The medical technology area (MTA) is the central focus of a nursing, diagnostic and treatment imaging hospital / clinic. Typically, it is not present in outpatient facilities, assisted living facilities for elderly or handicapped persons, or hospice facilities. Dedicated patient and services areas (P&SA) are of major significance in hospitals and clinics, as well as in assisted living facilities for elderly or handicapped persons, and hospice facilities. Typically an HCF needs between 60 to 100 square meters (m2) per bed, in addition to an area of equal or similar size for parking and facility access. With periodic upgrading of technologies, the relevant investment involved ranges from US$175,000 to APRIL 30, 2007 17 FINAL DOCUMENT