MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

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ENVIRONMENTAL
CARE AND WASTE REV NO
MANAGEMENT PLAN
EFFECTIVITY DATE

1.0 OBJECTIVE

1.1 To prevent transmission and/or spread of nosocomial infection.

1.2 To protect the environment and hospital personnel, patients, and visitors through proper
segregation of wastes and disposal.
1.3 To maintain ecological balance for the benefit of the Malolos City and individual medical
institutions through discipline on sanitation and proper disposal hospital wastes.
1.4 To comply with the requirements of other environmental laws, i.e. Republic Act 8749 or “The
Clean air Act”, RA 6969 or “Toxic Substances and Hazardous and Nuclear Wastes Control Act”,
RA 9003 or “Ecological Solid Waste Management Act” and RA 9275 or “Clean Water”.

2.0 SCOPE

This policy covers all the hospital personnel, patients, and visitors.

3.0 DEFINITION
3.1 General Wastes – comparable to domestic waste, this type of waste does not pose special handling
problem or hazard to human health or to the environment. It comes mostly from administrative
and housekeeping functions of health care establishments and may also include waste generated
during maintenance of health care premises. General waste should be dealt with by the municipal
waste disposal system.

3.2 Clean Recyclable Wastes – These are specific recyclable wastes such as papers, cartons, bottles
(plastic and glass), and cans that are identified in the hospital.

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

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3.3 Infectious Wastes – This type of waste is suspected to contain pathogens (bacteria, viruses,
parasites, or fungi) in sufficient concentration or quantity to cause diseases in susceptible hosts.

3.4 Pathologic wastes – Any body parts of human or animal that are also called anatomical wastes.
These wastes are sub-category of infectious wastes, even though it may also include healthy body
parts.

3.5 Radioactive Wastes – Includes disused sealed radiation sources, liquid and gaseous materials
contaminated with radioactivity, excreta of patients who underwent radionuclide diagnostic and
therapeutic applications.

3.6 Chemical Wastes - Consists of discarded solid, liquid, and gaseous chemicals, for example from
diagnostic and experimental work and from cleaning, housekeeping, and disinfecting procedures.

3.7 Pharmaceutical Wastes – Includes expired, unused split, and contaminated pharmaceutical
products, drugs, and vials that are no longer required and need to be disposed appropriately.
3.8 Sharps – Any items that can cause a cut or puncture wounds.
3.9 Sewage Treatment Plant (STP) - Water treatment facility for waste water discharge. Conduct
water treatment and water analysis following the significant parameters suggested by the DENR-
EMB.

4.0 POLICY
4.1 All personnel shall be oriented on hospital waste management.
4.2 All personnel shall know how to segregate waste in their respective areas.
4.3 All personnel shall perform recycling of clean recyclable wastes namely papers, cartons, bottles
(plastic and glass), and cans.
New Revised Date: Originating Department/Unit
Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

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4.4 Level of compliance on proper waste segregation shall be monitored by Infection Control
Committee and Housekeeping Department.
4.5 All trash bins shall have a label and a color-coded plastic liner.
4.6 Complete set of trash bins shall be seen in patient’s rooms.
4.7 All comfort rooms shall only have yellow trash bins.
4.8 Areas where eating is prohibited shall only have black and yellow trash bins.
4.9 All areas performing invasive procedures shall have sharps container.
4.10 Chemical wastes (liquid form) particularly from Laboratory and Radiology shall not be discarded
in sinks.
4.11 Diluted disinfectants shall be allowed to be disposed in identified sinks if it is followed by stream
of water.
5.0 RESPONSIBILITY

5.1 Hospital personnel –adheres to proper waste segregation and disposal and utmost support to
hospital waste management.

5.2 Housekeeping personnel –properly handles, collects, and stores waste.

5.3 Infection Control Committee – monitors and evaluates compliance of proper waste segregation,
handling, collection, and disposal as well as continuous quality improvement plan for hospital
waste management.

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

PAGE 4 of 10
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6.0 REFERENCE DOCUMENT

6.1 RA 9003 also known as Ecological Waste Management Act of 2000

6.2 RA 8749 the Clean Air Act of 1999.
6.3 RA 6969 Toxic Substances and Hazardous and Nuclear Wastes Contract Act of 1990.
6.4 RA 9003 Ecological Solid Wastes Control Act of 2000.
6.5 RA 9275 Clean Water Act of 2004.
6.6 DOH Healthcare Waste Management Manual 3rd Edition of 2011

7.0 PROCEDURE
7.1 Guidelines on Handling Wastes
7.1.1 Hospital personnel as well as patients should be aware of health hazards/risks associated
with hospital wastes;
7.1.2 Wearing of Personal Protective Equipment (PPE) is a must for personnel handling waste
such as housekeeping, maintenance staff, and others;
7.1.3 Receptacles with color-coded bag should be strategically located;
7.1.4 Hospital personnel should know the purpose of handling wastes.

7.2 Guidelines on Primary Storage

No Color of Plastic Bags Types of Wastes

1 Black Non-Infectious, recyclable wastes
2 Green Non-Infectious, biodegradable wastes
3 Yellow Infectious wastes

7.3 Collection, Transport, and Disposal

7.3.1 Each patient’s room has three (3) trash bins that are properly labeled with common wastes
to be discarded in it.

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

PAGE 5 of 10
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a. Black bag for recyclable wastes inside the room

b. Green bag for biodegradable wastes inside the room
c. Yellow bag for Infectious wastes inside the comfort room
7.3.2 Housekeeping collects wastes daily or as needed protected with gloves and/or mask using
utility carts. They are monitoring the proper waste segregation using the daily
checklist/monitoring form on compliance to waste segregation.
7.3.3 Housekeeping cleans and disinfects receptacles and replaced removed plastic on trash bin
with new one.
7.3.4 The hospital has provided a storage area for different types of wastes.
7.3.5 Recyclable and Biodegradable wastes are collected by DENR-EMB accredited private
contractor (Greenergie Corporation).
7.3.6 Infectious wastes including sharps and pharmaceutical (vials) are collected by Integrated
Waste Management Incorporation) every 14 days (1st Tuesday and last Tuesday of the
month).
7.4 Steps for proper closure of container and its handling as follow:
7.4.1 Gently close by pulling down the lid of container.
7.4.2 Label the container indicating the name of forwarding department/area/unit.
7.4.3 Endorsed to housekeeping.
7.4.4 Make sure that sharps container is always available, discarded only with sharps, and not
reaching ¾ full.
7.5 Effluent Water Monitoring:
7.5.1 Evaluate the effectiveness of treatment and control.
7.5.2 Identify potential environmental problems and evaluate the need for remedial actions.
7.5.3 Determine the impact to the receiving water body.
7.5.4 Determine the effectiveness of the STP technologies adopted by the facility.

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

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7.6 Stack Emission Report:

7.6.1 Conduct air emission testing for the two standby Generator sets.
7.6.2 Conduct weekly Generator sets run testing.
7.6.2 Schedule of preventive maintenance for the two Gensets.
8.0 Environmental Management:
8.1 Conduct and effective Information, Education and Communication Program to inform and
educate all stakeholders, especially its contractors, workers, and local residents about
mitigating measures.
8.2 Implement a Comprehensive Social Development Program and submit a separate report with
CMR in DENR-EMB on a semi-annual basis.
8.3 Waste generated during operation phase shall be properly managed and disposed pursuant to
RA 9003.
8.4 Implement waste minimization, segregation, re-use and other ecological waste management
practices.
8.5 Planting of native tree species shall be undertaken either within the hospital site or in other
project area.
8.6 Established a totally smoke free workplace using the ACEMD guidelines.
8.7 Set an Environmental Objectives and Target;
8.7.1 Energy consumption - Ensure the future purchases are environmental friendly.
8.7.2 Water Treatment - Ensure that water sampling are carried out quarterly and assess
areas where improvements can be made.
8.7.3 Waste Management. - aim to increase volume of waste recycling.
8.7.4 Comply with e-waste.
8.7.5 Reduce use of materials containing hazardous waste.

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

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8.0 PROCEDURAL FLOW

START

WASTE
CLASSIFICATION

YELLOW
BLACK GREEN
(Sharps)
(Non-Infectious/Recyclable (Non-Infectious/Biodegradable
Waste)  Needles
Waste)
 Glass vials-tuberculin/insulin
 Paper & paper products  Kitchen left-over food  Capillary tubes
 Newspapers  Fish entrails, scale, and fins  Pipette slides/cover slips
  Blood lancets
 Boxes/cartons Rotten fruits & vegetables
 Glass & plastic  Used cooking oil  Rusty pins, nails, clips, and
 screws
 Used papers Fruits & vegetables peelings
  Scalpel blades
 Tetra packs, paper cups Non-infectious left over foods
 Stylet
 Packaging materials etc,
 Ampules
 Spike of IV tubings
 Aluminum cover
Discarded in BLACK TRASH BIN
Discarded in GREEN TRASH BIN  Broken glasses
 PPE
 Blood and Placenta

Collected by housekeeping daily or

Collected by housekeeping daily or as needed
as needed Discarded in SHARPS
CONTAINER THAT IS
PUNTURE-PROOF and LEAK-
Transported to BIODEGRADABLE PROOF
waste holding area
Transported to RECYCLABLE
waste holding area Tightly closed by staff once ¾ full
and endorsed to housekeeping
Collected by accredited hauler
GREENERGIE CORP.
Collected by the DENR-EMB
Accredited Haluler Collected by IWMI every fourteen
GREENERGIE CORP. (14) days

END

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

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ENVIRONMENTAL
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START

ORANGE
Chemical Wastes
(Radioactive Waste)
 Busted fluorescent bulb
 1125 (Iodine 125)
 Radiology chemical waste
 H3 - Thymidine
 Fixer and replenisher
 Chromium-51
 Developer and replenisher
 Iodine 131
 Laboratory chemical waste
 Cesium 137
 From machines
 Thing contaminated with these
 Soaking solution of anatomical
radioactive materials
wastes with formaldehyde
- Gloves
- Gauze
- Tissue papers
- Test tubes
- Cotton swabs
- Pipette tips
Discard in an empty punctured-
- Aluminum foil
proof container (preferably the
- Syringes
same chemical container) - one
- Used x-ray films, developers,
type of chemical per container.
and fixers
- Technicium 99m
- Tridium

Staff informed housekeeping

for collection

Discarded in ORANGE TRASH BIN

Transported to chemical waste holding

area in basement Allowed to delay to decay

Collected by housekeeping upon the

instruction of nurse-on-duty

Empty vials are forwarded to Pharmacy Collected by accredited hauler

Department for inventory. Collected by Note: Pharmaceutical wastes (expired
housekeeping personnel and placed in an medicines) are either returned to supplier
identified container. It is then collected and/or collected by accredited
by IWMI every 14 days. END pharmaceutical wastes collector

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

PAGE 9 of 10
ENVIRONMENTAL
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Collected by IWMI every fourteen (14)

days

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO
 MEDICAL DIVISION DOC NO.

POLICY MANUAL MED-ICC-02-14

PAGE 10 of 10
ENVIRONMENTAL
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9.1 Algorithm in Recyclable Wastes

New Revised Date: Originating Department/Unit

Prepared by: Reviewed by: Approved by:

Ms. Lorelie N. Foronda, RN Dr. Bethoven J. Go, MD Dr. Ferdinand Manuel J. Dacumos, MD
Safety Officer Medical Director President and CEO