Improvement Residency Project

Evaluation of medical solid waste management

At El Rantisi Specialized Pediatric Hospital

Prepared by:
Mahmoud El- Absi


Supervised by:
Dr. Bassam Abu Hamad
BSN, MSC, PHD
2014
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Acknowledgment:
Special thanks go to Dr. Bassam Abu Hamad who helps me to lead and guide to
do this project.
Also I would like to express my gratitude to infection control committee and all
Rantisi hospital staff in El Rantisi Specialized Pediatric Hospital who participated
in this project and who showed a real awareness for improvement.
Mahmoud El-Absi.













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No. Item Page No.
1 Introduction 4
2 Context of problem 5
3 Justification of the problem 6
4 General objective 7
5 Specific objectives 7
6 Literature review 8
7 Methodology and data collection 10
8 Ethical consideration, limitation, timing of project 12
9 Pre intervention tools and analytic results 14
10 Flow chart pre intervention 18
11 Pareto 19
12 Intervention 20
13 Post intervention 22
14 Stability and conclusion 24
15 Recommendation 24
16 Reference 26
17 Annex and time line 27

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1. Background
Medical solid waste is consider one of the most important challenges facing the
developing and developed societies, and that in the process of collection
transportation and final disposal, as it relates to the relationship of direct correlation
with the number of patients in the hospital and the proportion of services provided and
the coverage ratio and containing objects that for transmit infection (Al-Khudari, N,
1996). Medical waste is defined as the resulting medical activity, which could lead to
pollution of the environment or harm the health of the organism (Coad A, 1995).
Medical waste is a substance composed basically of solid or liquid waste, and there
are a variety of sources and are usually caused by the treatment, prevention,
examination, diagnosis or disease in humans or animals. Produced in huge quantities
every year millions of tons of medical waste from health care centers in the world.
The produces developed countries larger amounts of medical waste from developing
countries because of the technology used in health centers. The Environmental
Protection Agency in the United States defined medical waste as any waste resulting
from medical facility including hospitals, laboratories the medical centers conducting
experiments on animals or subdivision and health clinics (Eugene C1995).
Exposure to the medical waste could result in diseases and serious injuries, and
because there are several factors that lead to this, including: sever of microbe
infection or the presence of drugs and hazardous chemicals or radioactive materials
lethal all of these pathogens may enter the body in the following ways: by twitching
or cut the skin and through contact with the mucous membranes, and through
inhalation and through swallowing. Many individuals are exposed directly to the risk
of medical waste and more particularly nursing, followed by the rest of the staff at the
hospital as well as the staff cleaning inside and outside the hospital, in addition
visitors to the hospital facilities and the people who live near the hospital without
limiting this risk, which is also conducive to other effects on air, water and soil in
closed areas.


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1.1 Context of the problem
Many of the sick children suffering from weak immune systems and the lack of
response to treatment as they suffer from chronic diseases and receive daily hospital
patients; therefore any exposure to any infection lead to high risk on their patients
such as septicemia, pneumonia, resistant to antibiotic, wasted resources and the last
high rate of mortality. Another reasons for increased nosocomial infection are
increase number of admitted and readmitted cases to department with long time of
stay in hospital on suction procedure, urine catheter, medication giving, or infected
from disposal materials, all of these procedures are good point of source of infection.
Rantisi specialist pediatric hospital is a Hospital offers services from the third level to
the children of the Gaza Strip, the chronically ill and the need for specialized care.
Children Hospital was created in 2003, to provide specialized services (Level III)
covers the needs of a segment of pediatric patients, numbering to more than 600
thousand children, in the age group from birth to age 12 in addition to sick children in
need of service specialist until the age of 15 years. The hospital is currently providing
medical services as a hospital transformative for all areas of the Gaza Strip so as not
to receive any case only after prior coordination by a system that has been developed
by the Ministry of Health.
Ready as a building in 2006, has been appointed administrative staff to start operated
and transforming vacant building - which consists of two floors with an area of 2500
m2 each floor in addition to the ground floor (basement) - to a hospital provides
services considered at the highest levels possible in light of the lack of a lot of
resources necessary the basic level of human and programmatic and processing.
The second floor includes of five departments there are Oncology, Cardiology,
Nephrology, Neurology and Gastroenterology departments. The last floor is basement
floor there are director's offices. The hospital contains 56 beds (MOH, 2011).
The staff of Rantisi hospital are 281 person (Doctor, Nurse, pharmacist, medical
assistants as lap technician, administrative location and physiotherapist) and 26 of
cleaners. About the distribution of staff Rantisi hospital, the graph below shows the
percentages of each staff.
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STAFF NUMBER PERCENTAGE %
Nursing 82
29.1
Doctors 42
14.9
Pharmacist 9
3.2
Administrative location 86
30.6
Medical assistant 36
12.8
Worker 26
9.2


1.2 Justification of the project
There are some studies and projects for the management of medical waste in Palestine
with specific characteristics, but it did not take into consideration all sources of waste
and its impact on public health, as well as methods of proper disposal.
The problem of the study in the hospital Abdul Aziz Rantisi receives chronic
conditions when children fall beneath cases of HIV, cancers infectious diseases, or
critical chronic diseases which cover the cases of the sector fully and receives cases
from other hospitals, and here there is no in-depth study in terms of solid waste
Nursing
29%
Doctors
15%
Pharmacist
3%
Administrative
location
31%
Medical
assistant
13%
Worker
9%
PERCENTAGE %
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management and the lack of protocols carried out in this field. Also the amount of
solid waste extracted are not disposed perfectly and I wanted to highlight at this point.
1.3 Main objective
This study aims to examine and improve the reality of medical solid waste
management in the Rantisi Hospital, and by the views of the stakeholders, evaluated
and discussed, and then suggest appropriate solutions to the problems could produce,
this study is focus on examine the process of disposal of solid medical waste from the
ordinary waste how to handle with it and how to transport, treatment and final
disposal Finally, note that the medical waste are an important part of the hazardous
waste generated in the Gaza Strip.

1.4 Specific objectives
1. Conceive and give clear information about the current reality for the
management of medical waste and the technology used in the hospital.
2. Study and analysis of the views of the stakeholders, the management of
medical waste, and find out their views and suggestions to identify the
problem, and try to reach the right solution.
3. Assess the training needs of stakeholder's manage of medical waste in all its
stages in the hospital.
4. Develop appropriate mechanisms for raising the level of awareness in the
center and the concerned institutions in which the safety of employees and
processes that take place within it, and the surrounding environment, and by
working in the field.
5. Contributing to a proposal acceptable system possible to apply and has a cost-
effective and environmentally safe to deal with medical waste.
6. Assist in predict the size and weight of medical waste in the hospital to
contribute to the future planning process.



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2. Literature review
There are some studies and projects for the management of medical waste in Palestine
with specific attributes, and in spite of their usefulness, but it does not take into
account all sources of medical waste in those studies in general, for example Al-
Hmaidi, M. S. 1995 the review of solid waste management in the Governorate of
Ramallah, where information was good but limited with regard to medical waste, Al-
Khudari, N et al,1996 wrote a handbook on ways to reduce the risk of some solid
waste in general, and said some unsound practices in dealing with medical, Atyani
reviewed some of the practices for the management of medical waste in the Ramallah
Hospital and Surgical Khaled surgical hospital Al-Bireh city.
As well as the Zoarob, Z. K. et al 1997 Study of medical waste as part of the
hazardous waste in the Gaza Strip, where the study was limited to the Shifa Hospital
in Gaza City5. Abu kumboz AR M 2002 speak about environmental assessment of
hazardous waste management in Gaza strip, he assess about industrial and medical
waste and how to manage the wastes.
In 1998, during the Execution of the project to the Ministry of Local Government,
have been distributed "incinerators mechanism" in a some of hospitals for the disposal
of medical waste, where the temperature reaches more than 700 degrees Celsius But,
unfortunately, did not prove the efficacy of this project, due to lack of purifying
smoke from these wastes, which were issued by the toxic gases, and by following
these devices were not safe from the health and environmental aspects. Also
Massrouje, H 2000 talk about how to management of medical waste among health
worker in Gaza Strip she took all hospitals and protocols of final disposal. Researcher
found that 89.2% of her study group reported that medical waste may pose hazards to
workers in hospitals, and 69.2% of patients are plot to hazards, also 82.3% reported
hazards to society outside health care facility. In addition to 46.2% of cases are
exposed to needle stick injuries, and 20% exposed for body fluid. She recommended
to increase cooperation between ministries and increase authority power, raise the
health education among workers in medical field and promote of waste instrument to
control and decrease the hazards. There are some of project that authority did it
among Gaza strip,
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Project "twitching security," which was carried out by UNICEF, with the Department
of Preventive Medicine to provide a special container for the disposal of needles or
syringes after use, adding that the project has provided primary health clinics
sufficient quantities of these vessels. There are projects under implementation for the
disposal of medical waste in Palestine "Pilot project" for the management of medical
waste in a Ramallah hospital and funded by the United Nations Development Fund,
where the project is to provide a device autoclave.
The project will address the solid and medical waste, which include infectious
medical waste and blood samples, as well as from surgical or anatomy and residues of
drugs and chemicals and radioactive waste.
Completion of a guide to all the medical staff, to know the full details about the
medical waste treatment of all stages.
Training of personnel in the health sector on the mechanism of action of this project
before you start to implement it to ensure good results.
2.1 Definitions about types of solid wastes
2.1.1 Classification of medical waste:
There are many classification systems used to distinguish the various components of
the medical waste vary from one country to another or from one institution to another
The World Health Organization has proposed several categories of medical waste
generated by hospitals to European countries, As well as WHO has developed a
special scientific classification of developing countries in order to scientific purposes
and can be summarized in the following (EPA1989).
1-Non-hazardous medical waste (general waste).
2-Sharps.
3-Infectious waste (with the exception of the sharp infectious stuff).
4-Chemical Waste and Medical.
5-Other medical hazardous waste.

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2.1.2 Infectious waste:
Which contain pathogens, so that they pose a serious threat, such as culture from
laboratories, waste from surgery that contacted infected patients and any other
instruments or materials that have been in contact with infected person or animal.
2.1.3 Pathological waste
"Pathological waste" means: Human tissue and body parts removed by trauma, during
surgery or autopsy or studies and which is intended for disposal. Pathological waste
does not include teeth, hair, or nails.
2.1.4 Sharps
Any discarded items that can induce sub-dermal inoculation of infectious agents, or
any item that can easily penetrate the skin, puncture waste bags and cardboard boxes
including:
o Needles and syringes.
o Surgical, scalpel and razor blades.
o Pasteur pipettes, capillary tubes.
o Slides and cover slips.
o Shards of contaminated glass, and any other sharps items derived from
human or animal patient care, blood banks, laboratories, mortuaries,
research facilities and industrial operations.
2.1.5 Chemical waste:
Is consisting of chemical substance for example: laboratory chemicals, disinfectant
expired or no longer needed solvents, cleaning agents and others.
3. Methodology
3.1 Study design
Cross sectional descriptive analytic study was conducted through face to face
interviews with all the team in Rantisi Hospital departments about the commitment to
solid waste management measure by using investigation and brain storming with
quality and infection control committees to realize perceptions of staff on issues of the
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problem and to determine the practice gaps of the quality and evaluate solid waste
management in all Rantisi hospital.
Follow up the results of check list and observation pre and post intervention process for
handling equipments in Rantisi departments.
3.1.1 Indicators
1. Percentage of positive cultures and knowledge among individuals in the Rantisi
hospital departments for the managing of solid waste and separation of the
components.
2. Percentage of Rantisi hospital department's member's medical instruments
injuries and how to deal with it.
3. Indicate in the medical waste management plan that medical waste will be
contained separately from other waste as hazardous and chemical wastes.
3.2 Data collection
The data was collected as a start, daily assess the way of waste collection and how to
manage it for transferring to incarnation machine, checklist with (doctors, nurse, lab
technicians, and cleaners), observing how to manage the solid waste and how to transfer
(index 1+2). The data was analyzed on SPSS program version 17, and P-value equal
0.05.
Account the amount of daily waste and the average is 52-57 KG daily from all
hospital departments, and safety box collected weekly by small container
(accommodate 18-20 KG).
Checklist with (25 cleaners, 40 nurse, 10 doctors, 10 lab technicians), and
analyze the data.
Observation of doctors, nurse, and lab technicians how to disposal the waste
among departments.
Evaluate and efficiency the waste separation and treatment of solid waste after
collection and how to final disposal.

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3.3 Sample size
All dealers with hazardous waste in all of the health field, such as doctors, nurses,
pharmacists and workers and the industrial field, such as technicians and workers in
the hospital. Components from Rantisi hospital staff were 85 person, (25 cleaners, 40
nurse, 10 doctors, and 10 lab technicians).
Average of medical waste product for Rantisi units:
No departments Weight(KG)
1 Gastroenterology 3
2 Radiology (x-ray) 4.2
3 Neurology 10.2
4 Oncology 6.4
5 Cardiology 9.2
6 Doctors room 4
7 ICU 6
8 Laboratory 7
9 Nephrology 5.3
10 Total weight 55.3 KG daily
3.4 Ethical consideration:
Official approval from doctor of this course, and School of Public Health
approval written paper.
Hospital director agreement was obtained to perform my study; also the
infection control and quality promotion committees was agreeing to do this
program.
Confidentiality was maintained and oral agreement was obtained from
employees who participate in the study.
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3.5 Limitation of the project
During our working in implementation project many obstacles facing us:
Time constraints.
Lack of equipments.
Weak finance coverage for intervention by hospital managers.

3.6 Timing of the project
Procedure 9.2.14 15.2 19to1.3 1to31.3 15.to 31.3 1to10.4 15.to1.5
Approval for project
Problem assessment
Data collection
Checklist questionnaire
Assess collection and
waste disposal

Intervention
Post intervention

3.6.1 Timing of project steps
1. Going to head manager of hospital and got approval and give advices for help
to my project among the hospital 9.2.2014
2. Start investigate and evaluate by looking the way of collection the solid waste,
degree of cooperation between medical staff and infection control committee,
follow up the way of distribution and separation components of solid waste
from 15.2.2014 to 1.3.2014
3. Start checklist and questionnaire for members of medical staff(doctors, nurse,
other medical categories, and cleaners) and Committee of Quality
Improvement and The Infection Control ,start planning to intervention to
manage of medical solid waste 1.3.2.14 to 1.4.2014
4. Assess the way of Management of Solid wastes:
1- Collection 2-Transport 3- Disposal
And the way of
a- Dumping b- Incineration c- Recycling
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5. Intervention include training all interested parties and put posters in every unit
among the hospital, Delivery of handbook for each unit talks about the proper
disposal methods of solid waste management The Report mandated cleaning
company specializes in the development of containers for each element of
organic waste and solid 1.4.2014 to 10.4.2014
6. Post intervention put the result and evaluate degree of response and controls of
solid waste and give conclusion and recommendation. 15.4.2014 to 1.5.2014
4.1 Pre intervention tools and results analysis:
By observation (chick list) pre intervention for all the hospital staff included to the study
during work the results were:
48 person (56.5%) does not know about MOH protocol for medical waste
management.

The segregation waste were: 8.2% who said yes, 46% who said some
times, while 37% who said no.

30.6% of person who suffered from needle injects, 74.4% of them were
cleaners, 12% nurse, 7.6% lab technician, and 6% doctor.
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The educator's visits and give instructions were 61.2% said not had teach
from them.

Fifteen person of cleaners does not has Hepatitis immunization.
There are 54(63.5%) of the sample does not trained before to how handle
with medical waste, and 54(63.5) who desire to training and take courses.

The way of disposal wastes were: 40% by container in front of hospital,
40% said by incinerator, and 20% others (The municipality vehicle, and
burn in open area).
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The evaluation of waste management, 16.47% consider excellent and
praised manage, 31.67%are said very good, 45.88% accepted and, while
5.88% are not accepted and consider workless.
The Ministry of health cooperation weak, 87.1% of sample cases said there
is no advertisement, pamphlet, booklet, or any special committee has
specialize in this field.




4.1.1 From the result identified the following causes of gap of solid
wastes managing:
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1. Lack of the existence of laws and regulations organize management of
hazardous waste, and disposal methods.
2. Source separation of waste in a healthy and safe almost non-existent. To
separate some types of medical waste such as needles and scalpels.
3. Knowledge of cleaners and health workers in the field of the proper disposal
of solid waste and to separate them incompatible emerged as uneven.
4. Poor communication between the infection control unit and improve the
quality and the tasks to be carried out in this field within the hospital wards.
5. Lack of equipment and safety tools for sharps, hazardous and biological waste.
6. Most of cleaners are not take Hepatitis immunization.
7. Lack of knowledge and absence of training.
8. Lack of supervision and follow up.
9. Shortages of cleaners and load of work over the staff.
4.1.2 And from the suggestion of population study:
1. Offend from the waste container that existing in front of the hospital
which led to the deformation of the place and work to increase
infection and annoyed citizens and source of bad odors.
2. Increase types of small containers and safety box among hospital units.
3. Collect blood bags in special biohazard container.
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4.1.3 Flow chart pre-intervention:


Flowchart above demonstrate the processing of collection wastes from the Rantisi
hospital after waste production from departments, then enquiry about the isolation
between hazardous, non-hazardous waste and the solid wastes. If there is no isolate it
will send directly to landfill or incinerator, if yes the next step is send the medical
reuse (IV centerline tools, medical bottles non-hazardous, surgery instruments, sheets)
for autoclave and sterilizing unit, and the other waste (one use) send for container, by
the following steps showed that the isolation system is very week, only needle and
sharps through in safety box and transfer to incinerator in AL-Shifaa hospital, the
treatment of the waste only done by burning in special machine by high temperature
and I will speak about the machine next paragraph, and the other tools to treatment
(Scissors, scalpels , forceps) to auto clave machine in Ophthalmic hospital.

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4.1.4 Incinerator machine in AL-Shifaa Hospital
All safety box send to incinerator of Shifaa hospital, there are 2 machines, Italian
machine and can burn 90 KG in one stage, and Spanish which its modern than Italian
and can burn 200 KG in one stage, both of machine receive wastes from all north
hospitals and El-Nasr district hospitals, also UNRWA clinics. The machines works
only 8 am to 1 pm every day except Friday, the machines level of burn temperature
equal 900 C, every burn period equal 30 to 40 minutes, and every wastes change to
dust and ashes, then the trash car take the rest to landfill area (index 1).
4.1.5 Pareto graph
Using Pareto in defining the priorities in problem to be under intervention.

According to Pareto possible causes were identified as contributing factors to the
hospital quality for waste management, and ranking according to main cause as
following that indicated to concern on training and availability of instruments among
different units.
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4.1.6 Check list assignments of cleaner's workers among the hospital
The way of carry bags by cleaners sometimes be wrong, they drag it on the
ground.
Most cleaners do not know Type of wastes that are dealing with.
Bags of blood dripped to the ground without the attention of workers.
Sometimes putting sharp objects in the laundry or with ordinary waste.
If leakage of blood, some of them deal with it normally and does not use
disinfectants.
Holds cleaners bags in their hands to move it, and sometimes put them on the
ground, without the presence of a closed truck to transport the waste.
4.2 Intervention
According the pre intervention results hospital departments need to intervention to
increase knowledge and culture about importance of solid waste management, training
and reactivate the infection control and quality committees, increased average of
instrument tools for isolation the wastes.
Firstly the student of project met infection control and quality committees and discuss
the main problems with them and put them on the risk of problem by showed him the
results.
Then, support from infection control committee to provide supplies for the
implementation of prevent infection and continuous follow up.
Second start to action work and continuous instructions to hospital staff who interested
about the problem.
4.2.1 Training and education
Education is the important point in the intervention processing more than of 50% of the
population sample does not knew that there is a Palestinian IPC protocol, while no copy
of protocol found in the departments(only in cardiology unit and manger office), that
indicate to arrangement of lectures directed toward the staff including physicians,
nurses, technicians, and cleaners aimed to elevate the awareness level about protocol
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for medical waste management, the way of handle , these lectures were prepared with
the cooperation with the infection control and quality committees in the hospital
(index4).
Specification of booklets papers to each unit, about how to use safety box and other
measures to increase the isolate waste, precautions during waste collection and good
way for transferring, put instruction in every unit to describe how isolate hazardous
waste in special small container.

4.2.2 Hospital management support
Motivation and education program about individual control of solids wastes and
involving management support.
Meeting with infection control committee in Al Rantisi hospital, manager of cleaning
company, and all head nurse departments in the hospital including to put strategies to
improvement the ways of isolation of wastes and how to use tools for this procedure,
and applied this project to all departments in the hospital instead to this continuous
follow up and monitoring.

4.2.3 Tools for isolation
The second problem showed there is sufficient of safety and isolation for medical
wastes instruments in all units, I explained and show this importance procedure to the
managers of hospital and they understand the problem, they ordered to distribute
container and big plastic bags with special color only for hazardous waste like (blood
bags, contaminated gausses, safety box and so on) to increase level of quality manage
of solid wastes (index5).

4.2.4 Monitoring and follow-up
The third problem was lies the committee of quality and infection control neglected the
effort and strategies for assessment and follow up the procedures of infection control
and safety disposal medical waste, the researcher advice and give steps for precaution
at how to manage medical solid wastes.



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4.3 Post intervention
By monitoring of post intervention for the member among the study whose works in
EL-Rantisi hospital the result were:
Expansion number of employee who has knowledge about system of disposal
medical wastes.
Increase in knowledge about infection control protocols.
The hospital managers agreed with cleaning company to increase tools and
instruments to coverage units need for disposal wastes.
The infection control defined safety area to disposal safety box away from
people, to final disposal by send to incinerator.
The cleaning company pledged to immunize cleaner worker from Hepatitis
disease.
Quality committee assure to increase courses and lectures include transaction
with all type of medical wastes safety.

4.3.1 The results above shows the proportion of implementations done by study
population.
76% of study population were educated about how to deal with medical
wastes, the rest of the individuals apologized for the attendance.
80% of instrumental and tools to medical wastes controlling inside all units as
the hospital financial coverage.
100% perfectly choose good area to lay waste away from others.
education tools
special
disposal
area
immuniza
tion
isolation
wastes
booklet
inside
units
protocols training
Series1 76 80 100 100 70 100 76 90
76
80
100 100
70
100
76
90
0
20
40
60
80
100
120
A
x
i
s

T
i
t
l
e
Axis Title
post intervention results
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100% of cleaners will immunizing from hepatitis disease, and the company
will immunize any new cleaner.
70% of medical waste could be isolated (organic, hazardous, chemical).
100% distribution of booklets and pamphlet for all units and give tips and
guidance to members of each section.
76% of study population aware about infection control protocols.
90% of study population had training courses theoretically about managing of
medical waste.



The figure above show the percentage of comparison procedures done by population
inside the study pre and post intervention on evaluate and improve of medical wastes
inside EL-Rantisi hospital, whose know protocols, education and level of knowledge,
training to manage medical wastes, tools and instruments coverage among all units,
immunization for cleaners, isolation wastes inside the departments, booklets and
pamphlets explains about medical wastes management, and how to dispose the waste
safety.
4.4 Stability
According to the results, the hospital manager need more focused on medical wastes
specially the purpose of the existence of hospital is third level of take care of chronic
diseases and low immunity among children, and increase level of precaution among
employees.
know
protocols
education training
tools
coverage
immunizati
on
isolation
wastes
booklets
inside
units
special
disposal
pre intervention 56 61 36 15 12 10 40 40
post intervnetion 76 76 90 80 100 70 100 100
56
61
36
15
12
10
40 40
76 76
90
80
100
70
100 100
0
20
40
60
80
100
120
compare between bre and post intervention
pre intervention post intervnetion
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5. Conclusion
The political and economic conditions that have affected the Gaza Strip, one of the
factors that have hindered those with relationship management of medical waste as
required, and led to the weakness of human resources and material resources.
Most of the laws and regulations specific to medical waste is disabled within the
hospital, as well as the absence of the role of the Ministry of Health within the
hospital regarding the management of medical waste. No special mechanism to deal
with medical waste in the Municipality of Gaza, but most of them are dealing with as
ordinary waste. There is no a policy to vaccinate cleaners against some infectious
diseases such as hepatitis. Coordination among relevant institutions are low is not
governed by any system, such as hygiene and stores consumer unit in the ministry and
the hospital administrators.
Source separation of waste in a healthy and safe almost non-existent. To separate
some types of medical waste such as needles and scalpels and the like knowing that is
not in this field separation. Poor communication between the infection control unit
and improve the quality and the tasks to be carried out in this field within the hospital
wards
6. Recommendation
Presence a protocol be working to reduce increasing solid waste disposal
methods and the activation within the institution and in its application.
Re communication between units and hospital infection control committee and
quality improvement and continuous monitoring.
Integration of the working groups within company of cleaning educational
lectures and find ways guarantee them a risk prevention of solid waste.
Training programs for all categories of health and who are dealing with the
waste directly within the institution.
Periodic disclosure of categories of health and hygiene workers who deal with
solid waste and the early detection of injuries.
Immunization coverage for the cleaners, and regular monitoring for their
health.
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The establishment of landfills under the direct supervision of the Ministry of
Health and Environment Quality Authority.
Stay landfills under the direct supervision of the Ministry of Health and
Environment Quality Authority.
Issuing laws to prevent burning garbage in open places of assembly and burial.
Establish systems for the collection of medical waste and hazardous materials
and disposed of so that they are separate from the ordinary waste.
Development of financial regularity ensures the ability to cover the financial
costs of collection and separation processes, transportation, burning and burial.




















Page 26 of 53

References
Al-Khudari, N. Minimizing the Risk of Solid Medical Waste, Environmental
Planning Directorate, Ministry of Planning and International Co-operation, 1996.
Coad A. and Christen J, How are We Managing Our Healthcare Wastes,
SKAT, Switzerland, 1999. Department of Community Health, Birzeit University,
Primary Health Care Training, an Assessment of Needs in the West Bank and
Gaza Strip, 1995.
Egyptian Environmental policy program, Medical collection, treatment, and
disposal, chapter11.2010
Eugene C. Cole, Medical Waste Management, a Basic Guide for Central and
Eastern Europe, DynCorp, Biotechnology and Health Division, Durham, North
Carolina, U.S.A., 1995.
S. Abbasi, H. Wahba 2006, Management solid medical waste in hospitals
Damascus, Damascus University Journal of Engineering Sciences, vol 22, p 66.
United States Environmental Protection Agency, EPA, Managing and
Tracking Medical Waste, a Guide to the Federal Program for Generators, 1989.
Zoarob, Z. K. Hazardous Waste Management in the Gaza Strip, MSc.,
International Institute for Infrastructure, Hydraulics, and Environmental
Engineering, Delft, Netherlands, 1997.







Page 27 of 53

Indexes: Check list for solid waste management inside Rantisi hospital

1
2
3
4
5
6
7
8
9
11
11 ( )

12
13
14

15
16
17



Index 1
Page 28 of 53



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Index 2
Page 29 of 53


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Page 51 of 53

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Page 50 of 53





Index 3
Index 4
Page 52 of 53












Index 5
Page 55 of 53






Page 54 of 53







Page 53 of 53