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Abstract
Introduction The management of healthcare waste is a crucial issue for public health and the environment. To minimise risks, it is essential to ensure that the management of healthcare waste is meticulously applied. Additionally, among the evaluation methods adopted by the hospital hygiene department to monitor the degree of compliance. The aim of this study was to assess the degree of compliance with healthcare waste management before and after a training and support programme.
Methods This is a pre-experimental study based on two audits of healthcare waste management at Farhat Hached University Hospital in Sousse, Tunisia. All medical, surgical and laboratory departments were included. The first audit was carried out, followed by training of the responsible staff, which was carried out according to a cycle of training and coaching hygiene technicians, and finally, a second audit was conducted. The compliance rate is compared between 2021 and 2022.
Results When comparing the averages of the compliance percentages for the four audit areas, there was a statistically significant improvement between the years 2021 and 2022 in the availability of equipment and consumables required for the management of infectious and sharp healthcare waste (p=0.029) as well as intramural transport (p=0.014).
Conclusion The study highlights the central role of effective waste management training in promoting compliance, awareness and responsible practices. Constant attention and training are essential to maintain progress at Farhat Hached University Hospital. This helps create safer care environments, better public health outcomes and long-term sustainability.
- Healthcare quality improvement
- Waste Management
- Team training
- Audit and feedback
Data availability statement
All data relevant to the study are included in the article.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Several studies have been carried out to assess waste management, but without calculating the compliance rate. These studies were more qualitative than quantitative.
WHAT THIS STUDY ADDS
In our study, we calculated the compliance rate, which is an indicator, and then assessed whether it had increased or decreased. Our study also focused on training, and the positive impact of training on waste sorting, even if the means are not always available, we, therefore, act on practices, that is, sorting, which helps reduce the quantity of infectious risk waste.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Our study makes managers aware of the importance of ongoing training in the field because the most effective way to change behaviour is to insist and involve staff in the process, and this is not just limited to theoretical training.
Introduction
The production of medical waste is inevitable and poses risks to patients, staff, public health and the environment, necessitating proper management at the national and international levels, with important considerations regarding social and legal dimensions.1 On a social level, the lack of proper waste separation can give rise to concern and fear among the public. The sight of contaminated waste, such as sharps or biological substances, in ordinary bags, can generate a reaction of fear and outrage. It can also undermine public confidence in healthcare facilities and in the waste management system in general. Legally speaking, incorrectly sorting infectious healthcare waste (HCW) can have serious legal consequences, including fines, civil lawsuits, administrative sanctions and risks to public health and the environment. It is, therefore, essential that healthcare facilities and organisations responsible for waste management scrupulously comply with current regulations, and implement safe, standard-compliant waste management practices. According to the WHO data, the quantity of waste generated per hospital bed per day is 0.5 kg in high-income countries and 0.2 kg in low-income countries.2
In recent years, there has been a growing global concern about HCW management due to increased production rates, driven by factors such as population growth, high demand for healthcare services and excessive consumption of materials in medical facilities.3
HCW encompasses hazardous and non-hazardous HCW. Hazardous HCW includes infectious waste, sharp waste (SW), single-use needles, syringes and similar infectious residues. It also involves other critical items such as chemicals, pharmaceuticals and radioactive materials, making its management more complex. Needle stick injuries pose a significant risk of transmitting more than 20 types of bloodborne pathogens, such as hepatitis B virus, hepatitis C virus and HIV.4 Non-hazardous waste is waste that has not been in contact with infectious agents, hazardous chemicals or radioactive substances, such as packaging, unwanted paper. Therefore, it is considered safe for disposal with regular municipal solid waste and does not require special handling.
The issue of HCW management is growing, especially in middle-income countries such as Tunisia. Many cities, particularly those with university hospitals, are experiencing a rapid increase in waste production alongside the expansion of medical procedures. Thus, they face challenges in waste management despite existing national policies.5 In Tunisia, in the two university hospital centres in Sfax, needle stick injuries accounted for 85% of occupational exposures,6 while it is equal to 31.7% in France.7
A potential solution to improve these practices would be to provide continuous and targeted training to medical staff in these hospitals.8 It has been observed that healthcare professionals have insufficient knowledge about medical waste sorting, although this knowledge significantly improves after undergoing training.9
This study aims to audit HCW management before and after training healthcare professionals in the University Hospital of Farhat Hached in Sousse, highlighting the importance of capacity building in Tunisia.
Methods
Study design
A pre-experimental study, based on two audits on HCW, was conducted at Farhat Hached University Hospital over a 2-year period from November 2021 to December 2022, both before and after training.
Presentation of Farhat Hached University Hospital
Services
Farhat Hached University Hospital encompasses 40 medical and medical-technical services, covering various specialties, with a total capacity of 765 beds and 20 incubators in the neonatology department.
Healthcare staff
In 2022, the hospital employed a diverse staff of 2337 healthcare professionals, including physicians, dentists, pharmacists, nurses and care assistants.
Legislation
The study adheres to national legislation, notably decree no. 2008-2745 (28 July 2008), governing the management of HCW in harmony with national waste laws Law No. 41-96 of 10 June 1996.
Hospital policy on HCW management at Farhat Hached University Hospital
The hospital’s waste management policy aligns with national regulations and involves various stakeholders, including the hygiene service, the local unit for the management of HCW, the committee for hygiene and nosocomial infection control, administrative departments and healthcare personnel.
Responsibilities include ensuring proper waste management from production to final disposal, collaborating with authorised waste management companies, issuing Waste Tracking Forms and maintaining a register for waste traceability.
Waste management sectors
Four waste sectors are identified, including municipal waste managed by the municipality, infectious HCW managed by a contracted company, anatomical pieces (embryos, foetuses…) handled by the municipality through the hospital morgue and placentas managed directly by the hospital.
Equipment and consumables
Infrastructure, equipment and consumables, such as centralised storage facilities, intramural collection and transport equipment, and a variety of consumables, are maintained and supplied regularly.
Study site
All medical, surgical and laboratory services were included in this assessment, except services that did not have healthcare activities (sterilisation unit, internal and external pharmacies).
Measurement tool
An audit grid inspired by National Agency for Waste Management’s guidelines was employed, focusing on resource and practice assessments for waste management.10 The grid for the services included had two parts: The first part concerned the audit of resources and the second concerned the audit of practices, covering the stages of sorting, packaging and collection. The assessment was conducted annually.
Data collection
The data collection occurred in three steps as follows:
Step 1
Assessment of the inventory (November–December 2021): An audit of resources and practices was carried out by a single visit per department or site before training.
Step 2
Intervention was made during ten months (January–October 2022) in the form of training sessions for all healthcare professionals generating HAW, door-to-door support sessions regarding all services provided by healthcare security service professionals for all staff. A hygiene technician visits each department once a month, to raise awareness among healthcare professionals who provide care, as well as supervisors in departments responsible for supplying black and yellow bags, and workers responsible for collecting and transporting waste. This monthly pass enables us to reach a large number of staff, given that there is a monthly changeover of trainee doctors and nurses, and certain staff availability on the day of the pass, with traceability via an attendance sheet. The choice of 1 month for the training cycle is explained by the minimal turnover of trainees (since the turnover is 1 month for paramedics, 3 months for interns and 6 months for residents). Additionally, we have observed that hands-on practical training yields greater benefits compared with theoretical, lecture-based training, which is why we have chosen to implement this approach.
Step 3
Postintervention evaluation (November–December 2022): An audit of resources and practices was carried out by a single visit per department or site after the training.
Variable definitions
Non-hazardous HCW includes11: ordinary waste (OW): Waste that has not been in contact with infectious waste, hazardous chemicals or radioactive substances. Waste includes paper, cardboard, plastics, textiles, food and packaging. This waste type makes up most of the waste generated at healthcare facilities.
Hazardous waste
Pathalogical waste (human cells, blood or organic products).11
Infectious waste: Any waste contaminated with blood/ body fluids or laboratory cultures.
Sharp Wast (SW): needles, scalpels, etc.
Pharmaceutical waste: Pharmaceuticals that are expired, unused, spilt or contaminated. Examples include antibiotics or other prescribed drugs.
Cytotoxic (antineoplastic) waste: Cytotoxic waste includes outdated or excess pharmaceuticals used for chemotherapy or cancer treatment. This waste stream also includes contaminated materials from drug preparation and administration.
Chemical waste: Waste includes discarded or expired solid, liquid or gaseous chemicals. Examples include cleaning and maintenance chemicals or diagnostic laboratory reagents.
Radioactive waste: Waste materials contaminated with radionuclides. These materials are generated during patient treatment with radionuclides, imaging procedures or laboratory activities.
Data analysis
Data collected were entered and analysed using SPSS software version 20. Qualitative variables were described in the form of numbers and percentages. Quantitative variables such as compliance rate were presented as mean±SD and compared using Student’s t-test. A 5% risk of error was used to analyse the results.
Patient and public involvement
Patients were not involved in this study.
Results
Evaluation of the availability of equipment and consumables for the management of infectious and SW at Farhat Hached University Hospital in Sousse (2021–2022)
The audit was carried out at 50 sites. The management of hazardous HCW exhibited overall positive improvement between 2021 and 2022, with resources required for proper management being largely available. Compliance rates for various resource indicators showed improvement, ranging from 66% to 90% in 2021 and 68% to 100% in 2022. Notable enhancements were observed in many aspects of medical waste management during the assessment period, particularly with regard to the rationalisation of the use of equipment, the availability of collection media and the presence of containers suitable and marking of filling limit. However, some areas experienced a decline in compliance rates, specifically in container cleanliness, allocation of hazardous waste and awareness of waste sorting (table 1).
Compliance rate of availability of equipment and consumables necessary for the management of waste from healthcare activities with infectious risk at Farhat Hached Sousse University Hospital 2021–2022
Assessment of overall compliance by care units of the stages of the waste management circuit from healthcare activities with infectious risk at Farhat Hached University Hospital in Sousse (2021–2022):
Overall compliance rate according to the 2021–2022 HCW management stages
The adherence to sorting protocols ranged from 32% to 90% in 2021, showing an increase from 52% to 82% in 2022. Packaging compliance, which ranged from 22% to 96% in 2021, demonstrated improvement, ranging from 0% to 98% in 2022. In 2022, SW was packaged in durable, waterproof, hermetic mini collectors at a rate of 96%, up from 70% in 2021. Compliance with marking the filling limit increased to 94% in 2022, compared with 62% in 2021. Significantly, the volume of yellow bags for infectious HCW was appropriately adjusted to waste quantity in 98.0% of cases in 2022, marking a slight improvement from 96% in 2021. However, a notable observation was the complete absence (0%) of labels indicating the date of SW collector filling and the producing service’s name in 2022, in contrast to 22% in 2021. For intramural transportation, compliance rates ranged from 84% to 98% in 2021 and achieved 100% compliance in 2022 (table 2).
Compliance rate of the stages of the infectious and sharp waste management at Farhat Hached Sousse University Hospital 2021–2022
Compliance rate by care units according to infectious and SW management stages
A notable improvement is evident in the compliance rates over the 2 years, with 74.28% of departments (n=26) achieving an overall compliance rate exceeding 75% in 2021, compared with 80% of departments (n=28) in 2022. Laboratories consistently exhibit the highest compliance rates in both years. Conversely, surgical services within the gynaecology department show the lowest compliance rates, recording 66.54% in 2021 and 65.76% in 2022 (table 3).
Compliance rate for the management of infectious and sharp waste by service at Farhat Hached University Hospital
Central storage of infectious and SW
Total compliance held steady at 73.33%, indicating overall stability despite improvements in specific areas such as extramural and intramural transportation, healthcare workers responsible for waste collection and waste traceability. Notably, central storage compliance declined from 100% to 70% (table 4).
Overall compliance rate for central storage of healthcare waste at Farhat Hached University Hospital 2021–2022
Comparison of different areas before and after training
Statistically significant differences were observed in the availability of HCW management equipment and consumables (p=0.029) and intramural transport (p=0.014) when comparing average compliance percentages between 2021 and 2022 (table 5).
Comparison of overall compliance rate before and after training
In terms of health economics, the training programme has resulted in a gain for the hospital since the quantity of waste has decreased from 212 978 kg in 2021 to 151 342 kg in 2022 and the hospital pays the subcontractor per kg of waste treated. This decrease can be explained by the impact of the training on the most important step in waste management, which is sorting.
Discussion
Strengths
The nature of the study: we adopted a rigorous methodology with pretraining and post-training audits, enabling us to assess the impact of training on waste management practices. The inclusion of all medical, surgical and laboratory departments (with the exception of certain specific departments) guarantees a complete and representative overview of waste management in the hospital. The audit was based on observed practices: One of the major strengths of this study is the use of audits based on observed practices rather than self-reported statements. This offers greater reliability and accuracy in data collection, as it minimises the subjective biases and potential inaccuracies often associated with self-reported responses.
Limitations
Non-application of regulations: Although national legislation and decrees concerning the treatment of SAR exist, they are unfortunately not applied. Staff variability: The constant turnover of staff between 2021 and 2022, notably due to retirements as well as the regular rotation of interns, residents and trainee nurses, could have a significant impact on the results and sustainability of care practices, given that these groups make up a major share of care producers. Single audit: Conducting a single audit per department or site before and after training may not fully reflect daily practices. No control group: Without a control group, it is difficult to attribute observed improvements solely to the training intervention. Potential for response bias: Awareness of being evaluated may modify staff behaviour, which could influence audit results. In a HCW management audit, it is crucial not to consider a compliance rate of over 75% as adequate. Setting an arbitrary threshold can mask potential shortcomings. While aiming for 100% is the ideal goal, compromises may be necessary. Compliance rates should be used to identify areas for improvement and allocate resources effectively. By using them strategically, we can make progress towards safe and effective infectious waste management. The analysis of HCW management at Farhat Hached University Hospital in Sousse, between 2021 and 2022 revealed progress with some persistent gaps. Training had positively influenced overall compliance with standards, yet additional efforts are needed to reinforce and sustain medical waste management. Comparing the audit domains, there was a notable improvement from 2021 to 2022 in equipment availability and intrahospital transport (82.25–89.12; p=0.029 and 95.63–100.00; p=0.014), primarily attributed to 2022 staff training. However, this has appeared insufficient, indicating a widespread need for further training, especially in waste definition and sorting. HCW management remains challenging globally, including Tunisia. The Hospital Hygiene Department of Farhat Hached University Hospital conducts annual systematic audits, offers training sessions and supports healthcare professionals. In Tunisia, the 2008 decree mandated waste management units in health facilities, emphasising information sharing and training,10 supported by the 2015 Tunisian standard NT 106.85–106.93 regulating HCW packaging.12 Globally, infectious HCW necessitates careful handling. Considering the proven effectiveness of this training programme, the hospital’s hygiene department has decided to incorporate it into the regular responsibilities of hygiene technicians. This will ensure seamless integration and continuous training for each new healthcare professional and will also enhance awareness among existing staff, as changing behaviour is often the most challenging aspect. Continuous education and training for healthcare staff significantly contribute to better waste management.9 13 Studies recommend integrating training as a crucial measure for improving HCW management in healthcare facilities.9 Repetitive training is vital for enhancing medical waste management among hospital staff, and continuous training can improve healthcare personnel performance.8 14 15 Following the training programme, improvements were observed in equipment and consumable availability in 2021 and 2022. However, financial constraints persist in meeting the increased waste quantity.16 Despite improvements, labelling inadequacies persist due to insufficient training or resources.General HCW comprises 75%–90% non-hazardous waste, but proper infectious waste management is essential to avoid health risks. Inadequate handling of sharp objects, leading to needlestick injuries, can result in severe psychological and physical consequences.17–19 Developed countries practice colour-coded and labelled waste sorting, while implementation varies in developing nations. Challenges include inadequate source sorting, lack of colour-coding and insufficient waste composition records. Direct involvement of top healthcare management is crucial for providing resources and guidance, ensuring effective HCW management at Farhat Hached University Hospital.17 Other actions in addition to training may be needed to ensure lasting change at the hospital. This mainly includes ensuring the continued availability of yellow and black bags, as well as care carts adapted for the placement of yellow and black bags and sharps collectors. Since there are periods when there is a shortage of these bags, supervisors on duty are sometimes required to make do with what is available, despite the fact that this is not compliant (use of yellow bags for OW and vice versa).
Conclusion
The evaluation of HCW management at Farhat Hached Hospital Sousse (2021–2022) shows improvement, but certain areas need ongoing attention. Though training enhances compliance, extra efforts are necessary for sustained progress. Effective waste management training ensures compliance and offers cost savings. It reduces hazardous waste, promoting proper sorting and identifying materials for recycling or reuse, leading to further cost reductions. In summary, vital waste management, training fosters compliance, awareness and responsible practices, creating safer healthcare environments, better public health outcomes and sustainability.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Ethics approval
We obtained approval from the heads of departments prior to commencing the audit, and all data used required authorisation from the head of hospital hygiene service, the head of the healthcare waste management unit and the general director of Farhat Hached Hospital in Sousse.
Footnotes
Contributors SC and MM elaborated the study protocol, IL did the two audits, SC and IL did the training for the staff, SS and RM wrote the draft article, SC supervised the survey, AA, OE and MN revised the article, MM validated the final version of the article. SC is the guarantor in the contributorship statement.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.