SURVEY OF L EGISLATION IN ES T ONIA AND THEIR IMPLICATIONS TO THE OPERATION OF HOSPITALS

1. SURVEY OF LEGISLATION IN ESTONIA AND THEIR IMPLICATIONS TO THE OPERATION OF HOSPITALS U.Raid June 2003

2. ONE OF WTC HOSPITAL BUILDING

3. WTCH STARTEGIC PLAN • Due to this project we decided in aprill to rise following priorities for this and next year of the Nursing Development Startegic Plan: • Health care waste management issues • Hospital infectious control • Restructuring cleaning service  Themes are strong ground to the safety and quality

4. INTRODUCTION • Hospitals generate more than two million tons of waste each year. • Most health care wastes are simply common wastes similar to household and commercial trash.  some wastes pose real health threats to workers and the community. • The mismanagement of this waste or the use of inadequate or harmful treatment technologies can further compound the threat to public health. • Important to fulfill the medical ethic to "first do no harm“ good philosophy for stuff training

5. HOW?  WHO SUGGESTIONS • The first step is waste minimization and segregation. • Minimizing waste not only protects people and the environment,  it can save facilities amounts of money. • Waste minimization techniques include: segeration, source reduction, resource recovery and recycling. • In internet founded several ideas how reduction waste, for example: • proof documents on the computer screen before printing, • establish a company-wide double sided coping policy, • reuse envelopes, • use envelopes without plastic windows, • donate old journals to the other facilities, • repair and reuse pallets or return them to the supplier, • purchase product with minimal packing and/or in concentrated form etc.

6. RISK FACTORS… • The risks to waste workers and hospital personnel who handle health-care wastes are currently being investigated. --> have to check out from databases! • There has been no attempt in Estonia to study the needs and problems associated with hospital environment and security that arise in the course of practical work and nursing stuff consciousness. • Culturaly sensitive case  health care stuff and waste workers sometimes refuse to handle the wastes. • Safe waste management systems are lacking in many health care establishments and countries • Low-cost options are often polluting and are therefore indirectly potentially harmful to human health. • The absence of management however also puts human health at risk. • Significant improvements can however be achieved by management options such as purchase policies, and isolation and proper treatment of key segments of the waste. (World Health Organization/April 2000).

7. There are a number of reasons leading to improper exposure to health care wastes: • Lack of awareness about the inherent hazards caused by improper management of health care wastes; • Insufficient allocation of resources (financial and human) for the safe management of the wastes; • Improper control of the waste management system; • Absence of a national policy for the management of health care wastes; • Lack of or inadequate regulatory framework, and insufficient evidence on the negative impact of health-care wastes on certain professional groups. • Insufficient information on sound waste management and treatment options and their benefits.  In addition, the lack of political will to develop and implement a proper management system plays an important role on the management of health care wastes.

8. LEGISLATION IN EUROPEAN UNION • In European Union the decrease of waste quantity and its harmfulness is one of the main objectives. • The European Union legislation related to the waste is based on framework directives: • “Council directive on waste” (1975), • “Commission Decision Establishing a List of Hazardous Waste” (formerly European Waste Catalogue) (1994), • “Commission Decision Amending the List of Wastes” (2000) and its supplements (2001); • “Council Directive on Hazardous Waste” (1991), • “Commission Decision on the List of Hazardous Waste” (1994).

9. LEGISLATION IN ESTONIA • The basis of Estonian waste management legislation was established in the beginning of 1990. • Estonian legislation on waste management is continuously updated. • Estonian legislation is largely adopted and adjusted according to directives of European Union. • ORGANIZATION OF WASTE MANAGEMENT the Estonian Ministry of the Environment (on the state level) is the main waste management organizer. It coordinates planning and activities of different ministries, counties, rural municipalities (towns) and non-governmental organizations. • The waste management system that is still under the development has not yet assured the decrease of waste quantity, its harmfulness, re-utilization and environmentally sound disposal.

10. LEGISLATION IN ESTONIA • National waste management plan was passed by parliament and entered into force 04.12.2002. Needed also national hospital waste management plan! • In the scope of the cooperation program between the Ministries of the Environment of Estonia and Denmark  the Estonian Hospital Waste Management Plan was prepared in 2001. The final result of this plan was finding the best solution for hospital waste disposal together with the detailed implementation program. Program includes waste collection, transport and final treatment. We haven’t seen yet the results of project. • Pursuant to Waste Act the national waste management plan must be prepared one year later, therefore at latest 04.12.2003.

11. PROBLEMS • The additional problem is compatibility of requirements of the Waste Act, Packaging Act, Chemicals Act and legal acts developed on their basis, including also the harmonization of terminology. • Also the implementation of waste management legislation shall be more dependent on laboratory basis (the specification of hazardous waste and examination of hazardous waste disposal assumes in many instances the laboratory analysis, i.e. the waste samples for determination of landfill suitability, analysis of landfill monitoring samples etc. must be analyzed in designated or accredited laboratory). • Every waste holder must be sufficiently aware about the type, amount and origin of the waste under his management, including waste properties related to the waste management and health and environmental hazards resulting from these properties.

12. HEALTH CARE WASTES • Today the hospital waste management is episodic and national hospital waste management system (national plan) does not exist. • The particular problem is hazardous waste like tissues remaining from the surgery, surgery instruments, syringes etc. • The Ministries of the Environment and Social Affairs are aware of this problem. There exists a plan not later than 2005 to obtain 7 autoclaves for safe hospital waste management for the whole country. In the autoclave the wastes are sterilized at certain temperature and pressures and then pulverized and disposed in the landfills of natural waste.

13. HEALTH CARE WASTE MANAGEMENT • In bigger hospitals the sorting of wastes at the place where they are generated is implemented. • In our hospital we have the places where to keep (maintain) the health care wastes until they collected by special “team” who are responsible of final collection, transport and treatment. • Subsequent handling involves usually disposal into landfill, partly the wastes are incinerated and liquid waste (including chemicals) are directed into the sewerage. • Containers for medicinal waste (old medicaments etc.) that is generated in households, shall be placed in guarded local waste collection centers and county waste collection stations.

14. Wastes produced in health facilities include and amount in WTCH • SHARPS (syringes, disposable scalpels, blades etc.) • Amount - 700 l/per month, collected at first in canisters (NB! reusing hemodialysis fluid canisters) and after that collected by WME

15. SHARPS

16. Wastes produced in health facilities include and amounts in WTCH 2. non-sharps (swabs, bandages, disposable medical devices etc.),  still problematic there needed autoclaves and sterilisatsion before collected by WME

17. BLOOD AND ANATOMIC WASTE 3. blood and anatomic waste (blood bags, diagnostic samples, body parts etc.), amounts 90 t/per year

18. Microbiological and virological stuff 4. Microbiological and virological stuff  autoclaved and after that handled like usual household trash

19. 5. Röntgen products • chemicals (solvents, disinfectants etc.), • Radioactive • Toxic for excample quicksilver • Medical mud  almost dosn’t exists in our hospital

20. Wastes produced in health facilities include and amount in WTCH 6. Pharmaceuticals about 30 kg/per year, 7. Infectious (f.e. SARS),  still problematic and needed new approach! • KRISTEL’S presentation!