Solid waste management in primary healthcare centers: application of a facilitation tool 1

Abstract Objectives: to propose a tool to facilitate diagnosis, formulation and evaluation of the Waste Management Plan in Primary Healthcare Centers and to present the results of the application in four selected units. Method: descriptive research, covering the stages of formulation /application of the proposed instrument and the evaluation of waste management performance at the units. Results: the tool consists in five forms; specific indicators of waste generation for outpatients healthcare units were proposed, and performance indicators that give scores for compliance with current legislation. In the studied units it is generated common waste (52-60%), infectious-sharps (31-42%) and recyclable (5-17%). The average rates of generation are: 0,09kg of total waste/outpatient assistance and 0,09kg of infectious-sharps waste/outpatient procedure. The compliance with regulations, initially 26-30%, then reached 30-38% a year later. Conclusion: the tool showed to be easy to use, bypassing the existence of a complex range of existing regulatory requirements, allowed to identify non-conformities, pointed out corrective measures and evaluated the performance of waste management. In this sense, it contributes to decision making and management practices relating to waste, tasks usually assigned to nurses. It is recommended that the tool be applied in similar healthcare units for comparative studies, and implementation of necessary adaptations for other medical services.


Introduction
Services provided in healthcare facilities generate considerable amount of solid waste denominated as a whole, Healthcare Waste (HW). Much of this waste (75-90%) is considered similar to those generated in households (recyclable or not) (1) , while the rest, due to their hazardous characteristics (pathogenicity, toxicity and radioactivity) require different processes for management and treatment before disposal into the environment (1) .
The management of HW involves planning, implementation and monitoring of actions that aim to prevent exposure, ensure the safety of users and professionals involved, prevent the occurrence of environmental impacts while minimizing the generation of waste (1)(2) .
Although the management of HW is routinely practiced by healthcare facilities, studies in developing countries (3)(4)(5)(6)(7)(8)(9)(10)(11) indicate frequent inadequacies, such as inefficient management; failures in segregation and handling; lack of training and awareness of risks, insufficient human and economic resources for the right management; adoption of inadequate treatment techniques; lack of control over the endpoint and even shortcomings or absence of specific regulations.
In Brazil, in the last two decades, the legal and regulatory framework geared to HW * suffered progressive updates, involving the ministries of Health, Environment and Labor, ending with the establishment of the National Policy of Solid Waste in 2010. All these Brazilian regulations and directives, which are aligned and complementary, provide that any healthcare facility in the country, regardless of size and complexity of the service, is responsible for managing its waste, and must prepare, implement and monitor its Healthcare Waste Management Plan (HWMP).
HWMP is the document that describes all internal and external steps for the management of waste in healthcare services, in order to prevent occupational accidents, to avoid environmental impacts and to protect the public health (3,12) . It could therefore go beyond a simple mandatory document and become an important supporting tool management. However, it has been widely assumed that, in spite of it being a legal requirement, the implementation of HWMP has not been a reality in the country (3)(4)(5) .
The literature indicates that the simple formulation of the HWMP, involving multiple aspects such as sanitary, environmental, health, and safety of the workers, has been a major challenge for healthcare institutions. Factors such as the lack of economic resources for the purchase of materials or equipment needed and the shortage of human resources also hamper the subsequent stages of implementation and monitoring plan.
In 2005, a study covering 21 hospitals and 48 outpatient public units of the State of Rio Grande do Sul, Brazil (5) , found that 28,6% (hospitals) and 4,2% (outpatients units) had deployed a HWMP, and only 33,3% and 10,4% respectively had developed employee training programs. Five years later, a new assessment carried out in nine Primary Healthcare Centers (PHC), in the Brazilian state of Goiás (3) showed that none had HWMP or even a technician responsible for the management of waste. Therefore, another important obstacle for the HWMP is the lack of trained professionals to implement and monitor the plan, a task that is informally delegated to managers of units or nursing professionals, who do not have any systematic method to help them to carry out this demand.
The nursing sector has a key role in the management of waste, considering that is directly involved in the generation of HW and is often commissioned to the administrative management of healthcare units because of the understanding of the complexity and the organization of these services (4,13) . Knowledge about the regulatory aspects concerning the management of HW are essential for the nurses to assess the conditions of the workplace, to train their staff and to alert all other professionals involved as to the inherent risks and the need for proper disposal of different types of HW.
In practice, the presence of these qualified professionals has not happened, which is worrying.
In the surgery department of an university hospital in Egypt (14) , it was found that 29% of the nursing staff had a satisfactory notion of waste management. Nationally, a study directed to nurses of the Family Healthcare Strategy Program in the State of Mato Grosso (15) , found that only 20% knew the waste management steps.
It is noteworthy that the requirement of a HWMP deployment is not restricted to large generators, such inhalation therapy, bandages, immunizations, application of injectable drugs, collection of samples for laboratory tests, dental treatment and basic medication provision) are also called upon to properly manage their waste, according to the rules in force in the country (3,12) .
In December 2015, existed in Brazil 34,951 PHCs in activity (16) . Although each PHC contribute with a small portion of hazardous waste, this generation is

Method
This is a descriptive study, which used as a research method the multiple case study, applied in four PHCs

Presentation of the facilitation tool
All requirements and applicable legal requirements -for health, environmental and labor issues -were incorporated into the facilitation tool. The five forms (F-I to F-V) that make up this instrument are described briefly in the following. www.eerp.usp.br/rlae 5 Moreira AMM, Günther WMR.

Sorting and conditioning
Are actions to minimize the production of solid waste taken?
Is information available about which materials are recyclable or re-usable?
Is the quantity of chemical waste reduced, observed feasible conditions? Is hazardous and toxic chemical waste reduced in the most feasible manner before being discarded?
Is there a segregation process for Group A waste in the generation site?
Is there a segregation process for Group E waste in the generation site?
Is there a segregation process for recyclables and non-recyclables in the generation site?
Are there enough containers in order to avoid mixing infectious, recyclable and non-recyclable waste?
Is the recommended identification for infectious waste used?
Is the recommended identification for common non-recyclable waste used?
Is the identification for recyclable materials used?

Is the recommended identification for sharps containers used?
Do containers for conditioning the infectious waste comply with standards: rigid material, resistant to punctures, breaking, leaking and tumbling, have a smooth washable surface, rounded corners, pedal-operated lid, and infectious material symbols?
Are containers for infectious waste covered with milky white plastic bag, Type II, waterproof and resistant, and with infectious waste symbols in black color?
Is chemical hazardous fluid waste disposed in order to have specific treatment?
Is a specific container (e.g. a cardboard box) with label and the hazardous symbol used for packaging the medicines waste?
Is a declaration of chemical waste transportation sent/delivered to the external waste collection service?
Is a declaration of infectious waste transportation delivered to treatment to the external waste collection service?
Does the bin for packaging sharps in the generation site comply with the standards?
Is there a systematic way for adequate disposal of batteries and accumulators containing lead, cadmium and mercury?
Other special solid waste such as fluorescent lamps, are sent to re-use, treatment or adequate final disposal?
The plastic bags are resistant to break and leak?
The infectious waste bags are identified with biologic risk symbol, information about the generator (name of person in charge or department) and data of exit?

Internal collection and transportation
The internal routine for collection is separated by type of waste to comply with biosafety standards?
Is an exclusive wheeled cart used to collect infectious waste?
Is the wheeled cart to collect infectious waste identified with the risk symbol, colors and labels, compliant with legal and standard requirements?
Is there a wheeled cart for common and recyclable waste collection, avoiding that bags of waste remain placed on the floor?

Storage
Is there a specific, identified site for storage of chemical waste?
The flammable waste that can ignite or explode, are stored following Fire Dept. guidelines?
Is there a specific shelter for storage of infectious waste?
Is there a biohazard symbol and warnings in the external infectious waste shelter?
The conditions of the external infectious waste shelter comply with the technical standards: sufficient capacity for the period between external collections; floors, walls and ceilings are smooth, washable, waterproof; floor has a slope of 2% towards the drain; drain connected to the sewer; door large enough for entering the carts; protection against vectors in the door entry; water tap; suitable artificial light, and screened ventilation openings (at least 1/20 of the floor area and not less than 0.2 m)?
The bags with waste are always kept in closed containers, and no spilling on the floor happens?

External collection
The external collection of infectious and sharps waste is performed twice a week or more?
Is there a systematic fashion for external collection of recyclable waste? Waste quantification (Figure 2) indicated that common waste (non-recyclable) was the highest generated amount (52 to 60%), and few recyclable was separate (5 to 17%), limited to cardboard boxes which were made available to independent waste pickers. The amount of hazardous waste was significant (between 31-42% of total generation). The largest amount of infectious or sharps resulted from the mixture of other wastes (recyclable and not) due to the lack of specific and clearly identified containers.  (Table 1).
Among the four PHCs, the average rate of total waste was 0.09kg/assistance, considering that the average rate of infectious waste was 0.03kg/assistance and 0.09kg/ procedure. It is noted that the rate infectious/sharps (A+E) waste generated by procedure exceeds two-tofourfold the rate per assistance, because procedures are the activities that effectively generate infectious waste. In the second diagnosis, carried out in 2012, the

Discussion
Inadequacies in the management of HW and consequent occupational and environmental situations of risk are often highlighted in studies conducted in hospitals in developing countries (5)(6)(7)(8)(9)(10)(11) . However, it is worth of note that little attention has been directed to the also worrying conditions in non-hospital healthcare facilities such as clinics (3,12) and emergency healthcare units (4) .
In this study, specifically referring to waste on In line with previous studies (3,12) , it was also verified the lack of job training to practice HW management in the PHCs surveyed. In this case, managers and / or nurses are due to assume this responsibility and individually seek for the improvement of their skills, to enforce the regulations. Moreover, if serious shortcomings are identified, these professionals can even suffer legal / criminal penalties imposed by regulatory agencies of health and environmental competence.
It is noteworthy that, despite the recommendations set out in studies conducted in different countries (5)(6)(7)(8)(9) regarding the imperative need to implement plans and institutional policies, the study was unable to find in the literature systematic and standardized methods in order to assist generators facilities to plan and implement these activities. The proposed tool appears to fill this gap and facilitate the performance of this function.
Although extensive, it is subdivided into forms that can be applied by one or more staff members, acquainted to these matter. The data thus collected will allow to feed generation and performance indicators.
It is also apparent that the most widely used generation indicator in literature -daily rate per hospital bed (kg of waste/bed.day) (  In the literature is also remarkable the lack of tools to assess the performance of the HW management.
Generation and performance indicators as proposed in the present study, lend themselves both to assess progress in the same unit over time, as well as for comparison and ranking of PHCs, at any given time.
In the PHCs under study, the documented way of exposing the nonconformities served as a warning, however it was not enough to motivate their managers to invest in adapting the management of HW. Limiting aspects considered were: the delay in political decision of the PHC responsible for the management, and the lack of human and financial resources to make the needed repairs and improvements.

Conclusion
The proposed tool seeks to fill the identified gaps Because it is an easy-to-handle tool, generating consistent and comparable results, it is recommended to apply this tool in other similar outpatient units, public or private services that have size, type of service and of similar HW characteristics.
It is also recommended that, for dental, veterinary and even hospitals this tool should be adapted to meet the specific needs of these units. For facilities in other municipalities, excluding Sao Paulo should be considered the state and municipal regulations in force.