Problem Statement

Before the beginning of the pandemic, biomedical waste was being segregated and stored in color-coded bins (having single liners) kept in the dirty utility room of the various patient care areas. From there, it is taken by the biomedical waste handlers to the temporary waste storage site and, thereafter, it is taken to the CBWTF for final disposal. However, management of COVID-19 waste has been a challenge, as it required a complete beginning-to-end rework of the system. In addition to the biomedical waste being stored in dirty utility rooms, biomedical waste is also being segregated and stored in doffing areas created across the hospital in various patient care areas catering to COVID 19 suspected/confirmed cases (Figure 1). Managing the large volume of COVID-19 biomedical waste in the midst of rapidly evolving guidelines and widespread paranoia, at the same time ensuring that the spread of COVID 19 infection is prevented within the hospital, has been a formidable challenge.

Figure 1. Prepandemic biomedical waste management process vis a vis process re-engineering for handling COVID 19 biomedical waste.

Structural and Process Re-engineering

Right from the point of waste generation, through to collection, intra-mural transportation to temporary storage facilities, to handing it over to the CBWTF operator, the entire process of biomedical waste management had to be re-engineered (Figure 1).

At our institute, which is an Institute of National Importance providing tertiary care to admitted patients, some patient care areas were converted into COVID facilities while other areas continued to serve non-COVID patients. The pre-existing processes for biomedical waste management are being continued in non-COVID areas during the COVID-19 pandemic. Processes were modified and evolved to manage COVID-19 biomedical waste generated from designated COVID-19 areas, which entailed its own set of problems to begin with. Our challenges and experiences can be better understood through the time tested Donabedian approach of structure, process, and outcome. ^{Reference Rublee9}

Major structural revamps were a formidable challenge. Dedicated wards in the hospital were earmarked for COVID-19 suspects and patients, which helped to limit the points of COVID waste generation. In line with the CPCB guidelines, the colors of bins were not changed, and the waste collected was double bagged. At the institutional level, a system of 3 red bins was introduced (Table 1).

Table 1. Three red bin system for biomedical waste management in doffing areas of the patient care facilities catering to COVID 19 suspect/confirmed cases

Abbreviation: PPE, personal protective equipment.

One red bin was meant for only the biosafety coveralls, which were sent to the hydrogen peroxide vaporization (HPV) facility for sterilization and re-use; another red bin was for collection and on-site disinfection of goggles and face-shields with sodium hypochlorite solution and the third bin was continued for contaminated disposable single use plastic items as per biomedical waste management rules. In view of projected surge in cases, it became imminent to be prepared for recycling personal protective equipment (PPE); therefore, red bin 02 was dedicated for collecting coveralls that were then sent to the HPV facility for sterilization and eventual re-use. ^{Reference Kumar, Killedar and Singh10}

The next challenge was waste collection. Dedicated staff in PPE with appropriate training were deployed to collect waste using dedicated trolleys. With widespread paranoia and fear, transporting a trolley labeled as COVID-19 within the hospital was fraught with challenges. A dedicated route plan was drawn with a dedicated elevator meant for COVID-19. A new temporary holding area was created, separate from the common biomedical waste collection point. The paucity of space was a major challenge as unidirectional traffic flow had to be established to minimize crisscrossing of paths with movement of people, staff, and hospital supplies. Procurement of biomedical waste collection bins and additional trolleys was done expeditiously to cater to increased demand owing to segregation and creation of new areas.

COVID-19 waste was handed over to the authorized services agency twice a day; however, the processing of waste at the CBWTF was not immediate because the CBWTF plant was overwhelmed owing to increased waste generation. This inundation was probably due to the increased use of disposables and general waste being contaminated and treated as biomedical waste. COVID-19 waste posed enormous challenges to the entire system of biomedical waste collection, which had a cascading effect on other health-care facilities as well. ^{Reference Mohan11}

At the beginning of the pandemic, in some health-care facilities, all COVID waste was being sent for incineration, a process that was corrected with increasing awareness. Periodic revisions of the CPCB guidelines have tried to address and correct the practice of discarding general waste from COVID-19 suspected patients and confirmed patients to yellow bags. Arrangements were also made to transport COVID-19 waste in dedicated trucks with requisite labels to CBWTF.

Various processes had to be changed. Every modification required new learning and behavioral change on the part of employees. Therefore, people are at the center of all processes. In the hour of crisis, owing to lockdown and logistic limitations, some employees could not turn up for work; however, available manpower was redistributed as needed.

The institute’s long-term investment on creating dedicated teams of infection control nurses (ICNs), nurses for continued nursing education (CNEs), and nursing informatics specialists (NIS) paid rich dividends. They have always been involved in training and awareness activities and continued the stride at the time of need. Our communication channels have stood the test of time due to pre-established systems involving ICNs and CNEs. A pre-set culture of continuous education and training came in handy when we had to train and re-train all cadres of staff with rapidly changing guidelines.

All new changes in COVID-19 waste and biomedical waste management were disseminated to all employees across the institute through informative circulars, which were further reinforced and reiterated during various on-going training programs. Regular training is being conducted for all cadres of staff and Trainer of Trainers (ToT) is being conducted to increase outreach. These efforts have improved dissemination of information and thus ensured translation to results on ground.

The overall outcomes have been very promising and reassuring thus far. All of the systems and processes that were put in place have resulted in the effective management of COVID waste. There has been a phenomenal jump in the amount of biomedical waste generated from COVID facilities, and the hospital system has been geared up to handle this surge; however, infrastructure at the CBWTF level needs strengthening. All biomedical waste generated is weighed before dispatching to the CBWTF, and data of daily biomedical waste generation is being maintained.