UNIVERSITY OF GONDER

COLLEGE OF MEDECINE AND HEALTH SCINCE

DEPARTMENT OF NURSING

Prepared by:-

No Name

1. Amare Molla 6. Netsanet Berhe

2. Aster Tadesse 7. Netsanet Melkamu
3. Berhan Tekeba 8. Ribka Nigatu
4. Desalegn Mitiku 9. Kidist Asmamaw
5. Melkamu Tilahun 10.Tiruamlak Getaneh

Submitted to:

Mr. Demeke Yilkal (MSc)

December 12/02/2019
Acknowledgement
First of all we would like to acknowledge University of Gondar and post graduate faculty for
incorporating this course in the curriculum of nursing department.

We would like to express our deepest appreciation and heartfelt thanks to our instructor Mr.
Demeke Yilkal (MSc)for give us a good knowledge, attitude and skill on Clinical Audit.

Our deepest appreciations goes to postgraduate librarian for providing necessary material that we
required. Lastly but not the list we would also like to thanks our group for valuable effort and
team work that we made during assignment work.

I
ABBREVIATIONS

LIST OF ABBREVIATIONS
BMW =Biomedical waste

HCW= Healthcare Wastes

HCWM = Healthcare Waste Management

IPC= Infection Prevention and Control

MoHS = Ministry of Health and Sanitation

NGOs =Non-Governmental Organizations

USA = United State of America

WHO = World Health Organization

WMP =Waste Management Plan

II
Contents
Acknowledgement........................................................................................................................................I
ABBREVIATIONS.....................................................................................................................................II
LIST OF ABBREVIATIONS..................................................................................................................II
LIST OF TABLE AND FIGURES......................................................................................................................IV
LIST OF TABLE.........................................................................................................................................IV
LIST OF FIGURES.....................................................................................................................................IV
Abstract.......................................................................................................................................................V
Introduction.................................................................................................................................................1
Significance of the audit..............................................................................................................................3
Aim..............................................................................................................................................................3
Objectives....................................................................................................................................................4
Audit Methodology.....................................................................................................................................4
Audit team...............................................................................................................................................4
Audit area and population........................................................................................................................5
Audit design and period...........................................................................................................................5
Inclusion and Exclusion criteria..............................................................................................................5
Inclusion criteria..................................................................................................................................5
Exclusion criteria.................................................................................................................................5
Audit sampling technique........................................................................................................................5
Audit sample...........................................................................................................................................5
Data collection tools................................................................................................................................5
Data collection method and analysis........................................................................................................5
Result..........................................................................................................................................................6
Discussion.................................................................................................................................................13
Conclusion.................................................................................................................................................15
Area of good practice............................................................................................................................15
Area needs improvement.......................................................................................................................15
Recommendation.......................................................................................................................................16
Action plan................................................................................................................................................17
Waste Holding and Storage Inspection Checklist......................................................................................18
Reference...................................................................................................................................................20

III
LIST OF TABLE AND FIGURES
LIST OF TABLE
Table 1: Basic characteristic of clinical audit on waste handling and storage in university of Gondar
hospital wards.............................................................................................................................................V
Table 2: Shows the result of waste handling and storage in Gondar university referral hospital, North
West Ethiopia..............................................................................................................................................6
Table 3: shows list of action plan to be performed in Gondar university referral hospital, North West of
Ethiopia.....................................................................................................................................................17
Table 4 shows list of Ethiopian guideline and WHO standards on waste handling and storage.................18

LIST OF FIGURES
Figure 1 shows compliances of pediatric ward against the standard at Gondar University, northwest of
Ethiopia, December 2019..........................................................................................................................10
Figure 2 shows compliances of pediatric ward against the standard at Gondar University, northwest of
Ethiopia, December 2019..........................................................................................................................11
Figure 3 shows compliances of pediatric ward against the standard at Gondar University, northwest of
Ethiopia, December 2019..........................................................................................................................12

Table 1: Basic characteristic of clinical audit on waste handling and storage in university of
Gondar hospital wards.

IV
 Project title:-waste handling and storage in pediatrics ward
University of Gondar Referral Hospital, Northwest Ethiopia,
2019.
Project team
1. Senior Clinician- 2. Project leader— the group members
3. Name of person from the 4. Other as necessary
audited department- -Tesfaye. A
-Dejene.
-Bezawite

Abstract
Background:Medical waste management has become a critical issue as it poses potential health
risks and damage to the environment, which has taken a central place in the national health

V
policies of many countries. In developing countries, medical waste management has not received
sufficient attention. This is because, very often, health issues compete for the very limited
resources. The World Health Organization has graded Healthcare Wastes as the second
most hazardous after radioactive wastes.

Objective: To improve waste handling and storage in University of Gondar Referral Hospital,
Northwest Ethiopia, 2019.
Methodology: Institutional based cross-sectional audit was employed from 24/ 03/12-26/03/12
E.C in University of Gondar Referral Hospital. Convenience sampling technique was conducted.
Data was collected using twenty two standardized audit proforma adapted from Ethiopian
guidelines and WHO standards/ checklist.

Result: Out of 22 standards 15(68%) pediatrics, 12(55%) medical ward and 13(59%) surgical
wards are consistent with WHO standard of waste handling and storage practice.Whereas 28 %
( pediatrics ward), 45 %( medical ward) and 31 %( surgical ward) of the standards were not
consistent with the standard.

Conclusion: Areas of good practice were,waste segregated where waste is generated, sharp
waste containers are puncture resistant and leak proof and use of PPE while handling and storage
whereas inappropriate segregation of healthcare wastes, overfilled wastes containers within the
hospitals and waste storage area near to patient & not restricted to authorized person should be
improved.

VI
Introduction

Healthcare waste” refers to any waste produced by, and as a consequence of, healthcare
activities. “Clinical waste” is defined as “. . . any waste which consists wholly or partly of human
or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products,
swabs or dressings, syringes, needles or other sharp instruments, being waste which unless
rendered safe may prove hazardous to any person coming into contact with it; and any other
waste arising from medical, nursing, dental, veterinary, pharmaceutical or similarpractice,
investigation, treatment, care, teaching or research, or the collection of blood fortransfusion,
being waste which may cause infection to any person coming into contact with it”(1).
Between 75% and 90% of the waste produced by health-care providers is comparable to
domestic waste and usually called “non-hazardous” or “general health-care waste”. The
remaining 10–25% of health-care waste is regarded as “hazardous” and may pose a variety of
environmental and health risks(2).

Categories of health-care waste: - The World Health Organization (WHO) has classified
medical waste into eight categories:

1. General Waste: 5. Chemical

2. Radioactive or physical hazard. 6. Infectious to potentially infectious waste
3. Pathological 7. Sharps
4. Radioactive: 8. Pharmaceuticals:

Cytotoxic waste containing substances with genotoxic properties (3, 4).

Containers for infectious waste should not be placed in public areas becausepatients and visitors
may use the containers and come into contact with potentially infectious waste
Basic three-bin system: The simplest and safest waste segregation system is to separate all
hazardous waste from non-hazardous general waste (which is generally of a larger quantity) at
the point of generation. However, to ensure staff and patients are protected, the hazardous waste
portion is very commonly separated into two parts: used sharps and potentially infectious items.
Consequently, the segregation into separate containers of general non-hazardous waste,
potentially infectious waste and used sharps is often referred to as the “three-bin system”.(4)

Globally over two million healthcare workers are exposed to infections(5) . The HCW can
transmit more than 30 dangerous blood borne pathogens (6). Poor HCWM is a problem
particularly in most developing countries (7). Several studies indicated that HCWM is still at
infancy stage (8).
In any health-care facility, nurses and housekeeping personnel are the main groups at risk of
injury, with annual injury rates in the USA at 10–20 per 1000 workers. The highest rates of
occupational injury among all workers exposed to health-care waste are reported by cleaning
personnel and waste handlers. In the USA, the annual rate is 180 per 1000 workers(5)

The systematic review done in Ethiopia shows the proportion of hazardous waste generated in
Ethiopian healthcare facilities was unacceptably high which ranged from 21 to 70%. Most
studies indicated the absence of proper waste segregation practice at the source of generation.
Treatment of the healthcare waste using low combustion incinerator and/or open burning and
open disposal of the incinerator ash were very common. Lack of awareness from the healthcare
staff, appropriate waste management utilities and enforcement from the regulatory bodies were
mainly identified as a common factor shared by most of the studies (9).

Health-care waste (biomedical waste) management is an integral part of any health care facility.
it is expected of every health care personnel to have proper knowledge, practices, and capacity to
guide others for waste collection and management, and proper handling techniques. Hospital
waste is a potential health hazard to the health care workers, general public(10).

Proper management of Biomedical waste (BMW) generated in a healthcare facility is one of the
most important functions of a healthcare worker (HCW) as its improper management not only
poses risk to human beings and environment, but may also invite legal action against HCW as
well as hospital administration. more emphasis needs to be laid on ‘mutilation of recyclable
waste’ and disinfection of waste’ by health care workers(11).

Poor management of health-care waste exposes health-care workers, waste handlers and the
community to infections, toxic effects and injuries(4).

Good health care waste management definitely depends on a dedicated waste management team,
good administration, careful planning, sound organization underpinning legislation, adequate
financing, and full participation by trained staff. Waste audits are an essential waste management
tool to enable healthcare providers to understand how their waste management system is
performing(12).
The management of healthcare wastes has of great importance to the welfare of the
people, the environment, the government and the world at large. This is due to the potential
environmental hazards and public health risks it poses. The wastes produced in the course of
healthcare activities carry a higher potential for infection and injury. Poor health care waste
treatment methods may produce poisonous chemicals. The World Health Organization has
graded Healthcare Wastes (HCW) as the second most hazardous after radioactive wastes.
(13)

Medical waste management has become a critical issue as it poses potential health risks and
damage to the environment, which has taken a central place in the national health policies of
many countries. In developing countries, medical waste management has not received sufficient
attention. This is because, very often, health issues compete for the very limited resources. (14)

Significance of the audit

Proper management of Biomedical waste (BMW) generated in a healthcare facility is one of the
most important functions of a healthcare worker (HCW) as its impropermanagement not only
poses risk to human beings and environment, but may also invite legal action against HCW as
well as hospital administration. So this audit will,
 Provides important information on the hospital biomedical waste handling, storage and
practice on the ward.
 Increases the awareness of the hospital administrator, head ward and matron on management
of waste on the ward.
 Also, becomes reference material for the person who conducts audit on the hospital.

Aim

 To improve waste handling and storage in selected ward University of Gondar Referral
Hospital, Northwest Ethiopia, 2019.

Objectives

 To assess the practice of waste handling and storage in selected ward University of Gondar
Referral Hospital, Northwest Ethiopia, 2019.
 To identify the gaps in selected ward University of Gondar Referral Hospital, Northwest
Ethiopia, 2019.
 To improve waste handling and storage practice in selected ward University of Gondar
Referral Hospital, Northwest Ethiopia, 2019.
Audit Methodology

Audit team
The team was composed from auditing members, senior supervisors, hospital cleaners and ward
head, and it is free of bias due sudden observation and interviewing is done.
Audit area and population

Audit was done on pediatrics and child health ward of Gondar university hospital with
involvement of patients, head nurses and cleaners during data collection period.

Audit design and period

Instructional based cross-sectional audit was employed from 5-6, 2019 in university of Gondar
referral hospital.

Inclusion and Exclusion criteria

Inclusion criteria
Healthcare waste management at pediatrics main ward of university of Gondar hospital.

Exclusion criteria.
Healthcare waste management at emergency unit of pediatrics and child health.

Audit sampling technique

Non probability convenience sampling technique is used

Audit sample
Since our audit is done primarily for observing the ward waste management system, and
comparing with WHO standard, we don’t use any health personnel population except head nurse
and cleaner at time of data collection.

Data collection tools

Data was collected using standardize audit preform adapted from National Health Care Waste
Management Guidelines Ethiopia, World Health Organization and Environmental Protection
Agency (EPA), South Australia.
Data collection method and analysis

Prospective data was collected by direct observation and interview using a standard check list of
WHO. The collected data were cleared and checked for completeness; data was analyzed using
manually and scientific calculator. Descriptive statistics was computed and the result presented
in tables and figures.
 Result
Table 2: Shows the result of waste handling and storage in Gondar university referral hospital,
North West Ethiopia.

S.no Activities Pediatrics Medical Surgical

1 Does waste segregation occur at the point where Yes Yes Yes
the waste is generated?
2 Is the collected waste properly segregated? Yes No No

3 Is separate container for hazardous and non- No No Yes

hazardous waste?
4 Are color-coded waste containers used in all Yes Yes Yes
facility areas?
5 Are waste containers properly marked and No Yes
Yes
labeled as per the waste they contain?
6 Are all waste containers free of leaking? Yes No
Yes
7 Are sharps containers puncture-resistant, and Yes Yes Yes
leak-proof?
8 Are poster to guide users displayed near waste Yes Yes Yes
bins
9 Are there a formal or informal health care waste No Yes Yes
separation guide line?
10 Are there waste containers emptied at the end of Yes Yes Yes
each day?
11 Are there waste containers filled no more than Yes No No
about three-quarter full?
12 Are container cleaned daily after waste is Yes No No
emptied?
13 Is segregated sharps bins and container closed Yes Yes No
during transport from ward to central storage?

14 Does everyone who will be handling waste have Yes No No

the appropriate PPE? (Gloves, tongs)
15 Is waste storage area located away from the Yes Yes Yes
 patients?
16 Is waste storage area secure and with access No No No
restricted to authorized personnel only?
17 Is waste storage area well ventilated? No No No
18 Is waste storage separated from food preparation Yes Yes Yes
area(s) and supply rooms?
19 Is stored waste clear within the following Yes Yes Yes
periods?
 Maximum 48 hours during the cool season
 Maximum 24 hours during the hot season
20 Is waste storage area clearly marked with No No No
warning signs (biohazard symbol)?
21 Is water supply available for cleaning purpose in Yes Yes Yes
the storage area?
22 Is refresher training available to all related staff No No No
at least yearly?
15 12 13
Total

Number of ward that meet the standard

Compliance against the standards: =___________________________________________× 100

Total number of standard

15
 Complianceof paediatrics ward against the standards = _______ × 100 = 68.2 %
22

12
Compliance of Medical ward against the standards = _______ × 100 = 55 %
22

13
Compliance of Surgical ward against the standards = _______ × 100 = 59 %
22

 22 standards are prepared based on WHO waste storage and handling protocol
Compliance of paediatrics ward against the standards

WHO standards
7

15

Meet the standards Not meet the standards

Figure 1 shows compliances of pediatric ward against the standard at Gondar University,
northwest of Ethiopia, December 2019
 Out of 22 standards, 15 standards are consistent with WHO standard, 7 standards are not
consistent with WHO standard.
 According to the audit 68.2 % of waste handling and storage practice done on pediatrics
ward of Gondar university hospital according to WHO standard where as 31 % not done
according to WHO standard.
Compliance of Medical ward against the standards

WHO Standards

12; 55%

Meet the standards

Not meet the standards

10; 45%

Figure 2 shows compliances of pediatric ward against the standard at Gondar University,
northwest of Ethiopia, December 2019
 Out of 22 standards, 12 standards are consistent with WHO standard, 10 standards are not
consistent with WHO standard.
 According to the audit 55 % of waste handling and storage practice done on pediatrics ward
of Gondar university hospital according to WHO standard where as 45 % not done according
to WHO standard.
Compliance of Surgical ward against the standards

WHO Standards

41% Meet the standards

Not meet the standards
59%

Figure 3 shows compliances of pediatric ward against the standard at Gondar University,
northwest of Ethiopia, December 2019
 Out of 22 standards, 13 standards are consistent with WHO standard, 9 standards are not
consistent with WHO standard.
 According to the audit 59 % of waste handling and storage practice done on pediatrics ward
of Gondar university hospital according to WHO standard where as 41 % not done according
to WHO standard.
Discussion
 According to WHO standard of health care waste management, waste segregation occur at
the point where the waste is generated in our institution also waste segregated at the point of
generation.
 According to WHO standard of health care waste management, waste must be segregated
according to its type/hazardous and a labeled and color coded separate container should be
available in our institution even though, a separate and color coded containers are available
but they are not labeled according the waste it contains as well hazardous and non-hazardous
waste discarded in same containers. This may due to poor performance of health
professionals.

 WHO recommends waste storage containers properly marked and labeled as per the waste
they containand should be free of leaking, in our institution even though container marked
and labeled based on waste they contain but container integrity will raised question
especially in medical ward.

 According to WHO standard of health care waste management, sharps containers must be
puncture-resistant, and leak-proof and also there should be poster to guide users displayed
near waste bins, in our institution also sharp container are puncture resistant and leak proof as
well as there are poster that guide user on how to use waste bin this should be appreciated

 According to WHO standard of health care waste management, waste must be waste
containers emptied at the end of each day and containers filled no more than about three-
quarter full in our institution even though waste container are emptied daily but most waste
container are filled more than ¾ of container this may be due to negligence of the staff as
well as poor regulation of responsible body this problem is observed in medical and surgical
ward.

 WHO also recommends waste storage area should be well ventilated, restricted to authorized
person, and must marked with waning sign (biohazard symbol).

 As we audited our hospital wards the above WHO recommendations are not practiced well,
this may due to poor performance of responsible body.
 According to WHO standard of health care waste management, waste storage should be
separated from food preparation area and stored nor more than 48 hours in our setup also
waste storage separated from food preparation area(s) as well as supply rooms and stored
waste clear within 24 hours this activity should be appreciated.

 According to WHO standard of health care waste management,water supply must be

available for cleaning purpose in the storage area which is well practiced in our setup

 WHO recommends refresher training and separate guide line must be available in the health
care facility.As we observe and ask the head nurse and cleaners there is no separate guide
line available in the ward. As cleaner said the training was given a long years ago, no training
is given in near years, this may due to resource limitation, ignorance of hospital
administrators.
Conclusion
Ethiopia having adopted the World Health Organization’s Standards on safe management of
healthcare wastes activities, has developed the national standards, policies and guidelines
on the management of healthcare wastes. Despite such developments, the findings of this report
have led to the conclusion that healthcare wastes produced at the Gondar referral hospitals
have not been properly managed. This has been the case because healthcare waste
management activities have not been adequately planned for implementation; available standards
not fully complied with; weak capacity to manage medical wastes; and low level of
awareness on the risk of healthcare wastes. This has led to high risk of infection to medical
personnel and the public at large.

Area of good practice

 Waste segregated where waste is generated
 Waste containers are puncture resistant and leak proof.
 Waste removed even hourly and daily base as well containers cleaned daily.
 Cleaners always wear PPE while handling and storing waste.

Area needs improvement

 Improper use of bins and bags in the segregation of healthcare wastes (Hazardous and non-
hazardous waste are always mixed with in one container).
 Inappropriate segregation of healthcare wastes
 Overfilled wastes containers within the hospitals
 Different color coded container labeled and marked as the same waste they contain.
 Waste storage area near to patient & not restricted to authorized person.
 There is no a separate guide line and training available in the ward.
Recommendation
Based on the gaps identified the following recommendations are given:

 The hospital managers should provide the right coloured containers for the segregation and
collection of healthcare wastes in the hospitals and ensure that all wastes be
appropriately segregated according to their nature and potential hazards and at all levels.
 The hospital management should put mechanisms in place to ensure that proper segregation
of healthcare wastes is done in the different wards of the hospitals.
 Health care professionals ought to segregate and discard wastes according to the type of
waste& in to appropriate place.
 Cleaners should better to restrict waste storage area for authorized person and also mark
waste storage area with warning signs (biohazard symbol).
 The management of the hospitals should ensure that healthcare wastes containers are
collected on a daily basis or when they are ¾ full and transported to the final point of
disposal.
 The hospital manager and administrator should make sure that there are trained and
certified personnel to operate the healthcare wastes equipment available in the hospitals.
 Action plan
Table 3: shows list of action plan to be performed in Gondar university referral hospital, North
West of Ethiopia.

S.no Activity Responsible body Time period

1 Disposing hazardous and All health care 25-30/03/2012

non-hazardous waste personnel in the
separately ward

2 Mark warning sign at waste Cleaner's, hospital 26-29/03/2012

storage area administrator

3 Preparation of health care Hospital 25/03/12-

waste management guide administrator 25/06/2012
line

4 Provide training to staffs Hospital Within 6 months

administrator
 Waste Holding and Storage Inspection Checklist

Name of the facility: ____________________________________________________________

Name of inspector: ______________________________Date of inspection: _______________

Table 4 shows list of Ethiopian guideline and WHO standards on waste handling and storage.

S.no Activities Target Evidence Data source

1 Does waste segregation occur at the point where the 100 WHO and
waste is generated? National
guideline
2 Is the collected waste properly segregated? 100
3 Is separate container for hazardous and non- 100
hazardous waste?
4 Are color-coded waste containers used in all facility 100
areas?
5 Are waste containers properly marked and labeled as 100
per the waste they contain?
6 Are all waste containers free of leaking? 100
7 Are sharps containers puncture-resistant, and leak- 100
proof?
8 Are poster to guide users displayed near waste bins 100
9 Are there a formal or informal health care waste 100
separation guide line?
10 Are there waste containers emptied at the end of 100
each day?
11 Are there waste containers filled no more than about 100
 three-quarter full?
12 Are container cleaned daily after waste is emptied? 100
13 Is segregated sharps bins and container closed 100
during transport from ward to central storage?

14 Are lids of waste bins and containers closed properly 100

during transportation from ward to central storage?

15 Does everyone who will be handling waste have the 100

appropriate PPE? (Gloves, tongs)
16 Is waste storage area located away from the 100
patients?
17 Is waste storage area secure and with access 100
restricted to authorized personnel only?
18 Is waste storage area well ventilated? 100
19 Is waste storage separated from food preparation 100
area(s) and supply rooms?
20 Is stored waste clear within the following periods? 100
 Maximum 48 hours during the cool season
 Maximum 24 hours during the hot season
21 Is waste storage area clearly marked with warning 100
signs (biohazard symbol)?
23 Is water supply available for cleaning purpose in the 100
storage area?
23 Is refresher training available to all related staff at 100
least yearly?

1. Prüss A, Giroult E, Rushbrook P, editors. Safe management of wastes from healthcare activities.
Geneva: World Health Organization; 1999. (2)

http://www.who.int/water_sanitation_health/medicalwaste/wastemanag/en/

2. Environmental Protection Agency (EPA). EPA guidelines. Medical waste management–storage,

transport and disposal. Adelaide, South Australia: Government of South Australia; 2003. 4 p.(15)
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3. 1 Doc 205: Inspection Checklist: Waste Holding and Storage This document was prepared with the
support of the US Centers for Disease Control under contract number 200-2010-3577 (16)
3. 2 National Health Care Waste Management Guidelines— Ethiopia (17)

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