1

A STUDY ON THE MEDICAL WASTE
MANAGEMENT AT THE NORFOLK AND NORWICH
UNIVERSITY HOSPITAL

by

KEVIN PAUL PUDUSSERY
(4905822)
Thesis presented in part-fulfilment of the degree of Master of Science
in accordance with the
regulations of the
University of East Anglia
School of Environmental Sciences
University of East Anglia
University Plain
Norwich
NR4 7TJ September 2011

© 2011 Kevin Paul Pudussery
This copy of the dissertation has been supplied on condition that anyone who consults it is
understood to recognise that its copyright rests with the author and that no quotation from the
dissertation, nor any information derived there from, may be published without the author‘s
prior consent. Moreover, it is supplied on the understanding that it represents an internal
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ACKNOWLEDGEMENT
I would like to thank first and foremost Dr David Benson for his invaluable academic
supervision and enthusiasm throughout this dissertation, as well as for the support and
confidence he gave me from every meeting and point of contact that occurred from start to
finish.
I would also like to thank Dr. Matt Cashmore who is the course director and other MSc
course staff, especially Dr. Alan Bond for their advice and guidance throughout the year.
Further thanks go to Chris Paul, Graham Corke, for allowing me to conduct this study at
Norwich and Norfolk University Hospital. Thanks must also go to the people who agreed to
undertake the surveys, without which the study would have seriously have been compromised.

Finally, thanks must go to all my friends and family for their continual support and
enthusiasm towards this study, for having confidence in my ability throughout the duration of
the course.


EU: European Union
BAT: Best Available Technology
3Rs Reduce, Reuse and Recycle 5

TABLE OF CONTENTS
I. ABSTRACT………………………………………………………………………… ii
II. ACKNOWLEDGMENT ………………………………………………………….…iii
III. ABBREVIATION……………………………………………………………………iv
TABLE OF CONTENTS 5
LIST OF TABLES 8
LIST OF FIGURES 9
CHAPTER 1: INTRODUCTION 10
1.1) Definition and Classification of Medical Waste 10
1.2) Waste policies and legislations in UK that applies to medical waste management 11
1.3) Medical waste Management in United Kingdom (UK) and associated problems 13
1.4) Why Medical Waste Management at NNUH: Justification 13
1.5) Overall Objective and Specific Aims 14
1.6) Organisation of study 16
2.1) Medical waste management in UK 17
2.2) Best Practices for Hospital Waste Management 19
2.3) Hazardous waste transportation 20
2.4) Medical waste treatment technologies 21
CHAPTER 3: METHODOLOGY 24
3.1) Introduction to methodology 24
3.2) Interview with the Waste Management Officer at NNUH 25
3.3) Participant Observation. 27
3.4) A Questionnaire survey about the waste management practices of Staffs at NNUH

4.3.1) Capital Investment and Operational cost (C1) 49
4.3.3) Volume and Mass reduction of medical waste(C3) 51
4.3.4) Environmental Impacts of the proposed technology(C4) 51
4.3.5) Public acceptance (C5) 53
4.3.6) Training and operational requirements(C6) 54
4.3.7) Occupational Health and safety including needle stick prevention(C7) 54
4.3.8) Analysis of the result: 54
4.4) Public Perception about Medical waste treatment technologies. 56
4.4.1) Demographic data 56
4.3.2) Public perception about medical waste treatment technologies. 57
CHAPTER 5: DISCUSSION 59
5.1) Waste management policy, plans and practice 59
5.2) Practitioner‘s perception towards medical waste management. 60
5.3) Alternatives for medical waste treatment and selection of Best Available Technology.
63
5.4) Public perception about various medical waste treatment technologies. 64
5.4) Limitations of the study 64
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6.1) Conclusion 66
6.2) Recommendations. 67
Reference 69
APPENDIX……………………………………………………………………………………………………………………………………… 67


Table 4.2: Comparison of the RCN guidance and NNUH waste management policy…. 33
Table 4.3: Calculations of GHG emissions from medical waste transportation. ……… 36
Table 4.4: demographic data of the people surveyed ……………………………………37
Table: 4.5: knowledge of employees about the constituents of medical waste …………38
Table 4.6: Ranking: Capital cost………………………………………………………… 44
Table 4.7: Ranking: On types of waste treated ………………………………………… 45
Table: 4.8: Ranking: Volume and mass reduction ……………………………………….45
Table: 4.9: Environmental impacts of various technologies…………………………… 47
Table 4.10: Ranking: Environmental impacts…………………………………………… 47
Table 4.11: Ranking: Public acceptance ………………………………………………….47
Table: 4.12: Ranking: Training and operational requirements ………………………… 48

Table: 4.13: Ranking: Occupational health and safety:…………………………………. 48
Table: 4.14: MCDA matrix ………………………………………………………………49
Table: 5.15: Demographic data of public survey ……………………………………… 50

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LIST OF FIGURES

Figure: 1.1: The overall objective of the project…………………………………………….10
Figure: 3.1: Flow chart showing the various processes involved in an Interview ………….21
Figure: 4.1: Composition of health care waste at NNUH ………………………………….34
Figure 4.2: Employees attitude towards medical waste management for different age
groups at NNUH ………………………………………………………………………… 38
Figure: 4.3: Knowledge about the hazardous nature of medical waste ………………… 39
Figure: 4.4: Frequency of waste going to wrong bin ………………………………………40
Figure: 4.5: Problems faced by employees during segregation of medical waste………….40
Figure: 4.6: Problems faced by employees during segregation of medical waste …………………41
Figure: 4.7: Knowledge of the employees as if when the medical waste bin should be sealed … 41

waste

Clinical/Infectious/medical waste, cytotoxic and cytostatic
medicines, batteries, health are chemicals and hazardous
properties, radioactive substances, X ray photo chemicals.
2) Non- Hazardous
waste.

Offensive/hygiene waste, non cyto-toxic and cyto-static
medicines, domestic waste, packaging waste, recyclable waste
food waste.

Table 1.1: Types of medical waste. (Source: The safe management of health care waste,
RCN, 2007)
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Clinical waste is divided in to two categories:
I. Infectious waste: - It is defined under the Controlled Waste Regulations 1992 and
controlled by Section 34 of the Environmental Protection Act 1990 as (DOE
1990a):
( a)‖ Any waste which consists wholly or partly of human or animal tissue, blood or body
fluids, excretions, drugs or other pharmaceutical products, swabs or dressings or syringes,
needles or other sharp instruments, being waste which unless rendered safe may prove
hazardous (including microbial (infectious), pharmacological and /or physical [e.g.
sharps] dangers) to any person coming into contact with it‖.

Health COSHH) Regulations requires the health care providers to perform risk
assessments for determining and minimizing any subsequent risks to staff, patients and
the environment. New standards for incineration were also introduced by EPA. The
European Union Incineration Directive (EU 2000) caused many of these plants to close
due to the increased stringency of the emission limits to air and water. The NHS and
Community Care Act (DoH 1990) made the segregation of clinical and non clinical
waste mandatory. In addition, EPA assigned local authorities for providing collection
services for clinical waste generated through treatment at homes or other residential
settings.

The Special Waste Regulations (DoE 1996), the Hazardous Waste (England and Wales)
Regulations 2005 and the List of Waste (England) Regulations 2005, guided partly by
the EU Waste Codes caused more health care waste to be classified as hazardous and
thus creating a need for them to be appropriately consigned. Waste Incineration Directive
compliance is a criterion for new incinerators. So some categories of waste will need to
undergo alternative treatment and will have high-temperature treatment or incinerations
as its only option (Tudor 2009). Environmental permits issued either under the
requirements of the former Pollution Prevention and Control or the new Environmental
Protection Regulations give exact specifications on the amount and types of wastes that
can be treated at a facility. Under the Special Waste Regulations and the Hazardous
Waste Regulations, there should be no mixing of hazardous and non-hazardous waste
and so proper methods for segregating different streams are necessary.

13 1.3) Medical waste Management in United Kingdom (UK) and
associated problems
As a largest employer and organization in UK NHS is responsible for most of the medical
waste in UK. It employs more than 1.3 million peoplew3 and runs 259 NHS trusts. The


The various ways to reduce the carbon foot print in hospitals are by making the right
procurement choices, introducing green travel plans, improving the waste management,
by implementing energy saving strategies (WHO, 2008; Michael 2006, Barrat et al, 2004;
Environmental health nursing, 2010). In regard to issues in waste management, higher
generation rates of medical waste due to improper segregation and waste disposal are the
key areas of concern. Waste transportation and end disposal is the area of concern in
medical waste management. Hence a study on the medical waste management is essential
to provide a structured master plan to reduce carbon emissions and hence towards
sustainability.
Health care facilities can decrease their green house gas contribution by (Environmental
Health Nursing, 2010)
 Recycling and buying recycling products.
 Reducing/preventing the waste generation
 On site treatment of waste
The argument her is that the waste management policy should target more on waste
minimization. Also, the perception of health care staff is highly critical towards waste
minimization. This study looks on the possibility of reducing carbon emissions by
reducing the medical waste generated and also by avoiding the unnecessary transport of
medical waste by building an onsite waste treatment plant.
Since one of the objective is to consider an on-site waste treatment plant at NNUH, the
public concern their perception towards various technology cannot be neglected. Hence a
study is also done to understand the public perception towards various technologies.

1.5) Overall Objective and Specific Aims
The overall objective of this project is to perform a study on the current medical waste
management at NNUH and to aims find out how hospital can benefit from improving
medical waste management practices. The various aspects of medical waste management
discussed in this study are shown in the figure 1.1
The aims of the project are:

1) Green house gas
emissions and other
problems associated with
the transport of edical
waste.
Medical waste
treatment and
disposal.
1) Medical waste
generation at NNUH
2) To find best available
technology for the
onsite treatment of
medical waste.
3) Public perception
towards various
medical waste treatment
technologies
16 1.6) Organisation of study
The dissertation is heavily concentrated on the medical waste management at NNUH.
Chapter 1 is the introduction and aims to give a basic background information‘s
regarding medical waste management and the justification for the topic. Chapter 2 looks
in to the current literature about medical waste management. The methodology used to
achieve the objectives and aims of the project is explained in chapter 3. The results of
the project are given in chapter 4 and the results are discussed in chapter 5 with
comparing it with the current literature and initial objectives. Chapter 6 concludes the
research giving some recommendations to improve the medical waste management at

Table 2.1: Healthcare waste generation in selected countries
Country
kg/patient/day
UK
5.5
Ireland
2.6
USA
2.2
France
1.9
Portugal
1.5
Belgium
1.4
Greece
1.4
Italy
1.0
Spain
0.6
Netherlands
0.6
Germany
0.4
Source: (krisiunas et al, 2000; Chung and Lo, 2003)
The medical waste disposal in UK has become very expensive and it is estimated that UK
spends more than £125 million for the treatment of Health Care Waste (Tudor et al, 2009).
Hence, there has been a growing interest among the various hospitals to find out different
strategies to reduce the amount of medical waste generated. Also, there has been increase in

medical waste in UK has ensured high standards of clinical waste disposal but failed to
decrease the amount of medical waste generated in UK. (NHS Estates 2000, NHS Estates
2002; Tudor, 2005; Salkin 2003). Safe handling and storage of medical waste is still a
problem in UK despite the strict regulations. (Audit Scotland, 2005; Blenkharn 2005)Also,
most of the literature on medical waste management concentrates on the developing nations
rather than developed nation, one of the reason being poor waste management legislations
and practices in developing countries. In order to understand the reason behind higher
generation of medical waste in UK and the problems in Health Care Waste (HWM)
management at the hospitals, we need to know about the best practise for HWM in UK.
19 2.2) Best Practices for Hospital Waste Management
Major changes have been made in the management of hazardous waste so that the
requirements of the European Hazardous Waste Directive are met. In accordance with this,
there has been a revision of the guidance document Safe Disposal of Clinical Waste by NHS
Estates. On the basis of this, the department of Health revised the joint-agency guidance and
it‘s publishing its final form as a 119-page document was done on the 30th November 2006,
under the gateway reference 6874 (Department of health, 2006). As far as the best practice of
hospital waste is concerned, this document is the latest reference from the government‘s end.
Moreover, it is very details and gives information regarding all aspects of waste management.
It also gives the mandatory and optional settings. This document actually replaces the Health
Services Advisory Committee‘s guidance document ‗Safe disposal of clinical waste‘ (The
Management of Health and Safety, 1999). Revision and updating of the 1999-guidance was
done so that we can take into consideration, the changes in legislation regulating the
management of waste, its storage, transportation, treatment and disposal, and health and
safety (Tudor 2009).
On the basis of this, concise 17-page guidance on healthcare waste had been published by the
Royal College of Nursing. This guidance is widely used in UK as the best management
practice. The RCN guidance include guidelines about the definition and classification of

reduced by 60%. The literature shows that the lack of knowledge and inefficient waste
management practices are the reasons for high generation of wastes.

2.3) Hazardous waste transportation
Unless treated using an on-site treatment technology, the clinical waste need to be transported
securely to a suitable treatment plant which has the license to treat clinical waste. The waste
transportation of hazardous waste has to comply with the strict regulations associated with it.
Due to this reason clinical waste transportation and disposal in UK is really costly (Blenkharn
2005; Tudor 2009). There is a significant amount of waste transport across UK and it is the
comparatively higher in England. It is a matter of high health and safety concerns. Also, in
addition to that it has various environmental impacts like Green House Gas (GHG) emissions.
(Tudor et al, 2005). The estimated figures for greenhouse emissions from waste transfer
station to disposal/management site is 4.3kgCO2eq/ tonne of waste.( Smith et al, 2001). The
literature shows that it is advantageous to avoid the hazardous waste wherever possible. By
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treating the waste on-site the wastes are confined to a limited space, there by making it more
convenient and minimize the risk to public health and environment.

2.4) Medical waste treatment technologies

Literature review s on waste disposal/ waste treatment technologies are rather contradictory.
Some of the most common technologies include incinerators, sterilization or autoclave,
irradiation, sterilization, microwave, chemical disinfection and secured landfill. According to
previous studies (Park and Jeong, 2001; Lee et al., 2004), about 49–60% of medical waste is
treated by various incinerations, 20–37% by autoclave sterilization, and 4–5% by other
methods. Incineration and steam autoclave sterilization are the main methods currently being
used and are considered mature technologies. Each of the technologies mentioned above has
some advantages and some disadvantages.
Incineration utilizes thermal energy to decline waste materials to non combustible residue or

treatment should be selected depending on the characteristics of the waste. Also with the
proper reduction of waste and preventing the waste containing chlorine a mercury entering to
the incinerator can reduce the environmental impacts of medical waste incinerators. While
none of the alternative technologies are totally risk free, they can be combined with an
effective program of waste reduction and segregation to reduce the environmental impacts
and financial cost of medical waste disposal.
The criteria‘s used to evaluate technological option should consider environmental, health
and economic factors (Batterman 2004). The best technology for the medical waste treatment
will be different for different hospitals. It may depend on the local conditions and the
requirement of the hospital. However WHO gives a list of factors to guide the selection of
best technology for treating medical waste (Pruss 1999). They are: -
 Disinfection efficiency
 Volume and mass reduction.
 Quantity of wastes for treatment.
 Infrastructure requirements.
 Options available for final disposal.
 Operation and maintanence consideration.
 Location and surroundings of the treatment site and disposal facility.
 Public acceptability
 Available space.
 Investment and operating cost.
 Health and environmental considerations.
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 Types of waste for treatment and disposal.
 Regulatory requirement.
 Occupational health and safety considerations.
 Training requirements.
Hence, it can be interpreted from the literature that, medical waste management is an area
of high concern due to the high generation of medical waste, improper segregation and

To collect primary data‘s
and understand the current
waste management policies
and practices at NNUH  Interview with waste
manager.
 Site visits/
Participant
observation
 Current waste
management policy
 The waste generation
data.
 Information about
medical waste
disposal.

To understand the
perception of staff towards
medical waste management  Participant
Observation

 Quantitative survey
 Selection of
technology

To understand the public
perception towards medical
waste management  Questionnaire survey

 Peoples knowledge
and views towards
various treatment
technologies.
Table: 3.1: Methodology for the research.
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I. The waste management policies should target more on waste minimization.

II. The health care workers perspective towards medical waste management is
critical towards efficient segregation and waste minimization.
Also a multi criteria decision analysis is used to find out the best treatment technology. A
quantitative public survey is also used to find out the perception of public towards the waste
treatment technologies
The methodology is explained in detail in the following sections.

3.2) Interview with the Waste Management Officer at NNUH

The purpose of the interview with the waste management officer at NNUH was to collect the
primary data and background information about the waste management practices at the