Kayakalp – Utility of a novel Indian tool for the assessment of biomedical waste management in a district hospital of Northern India

Ankit Chaudhary; Anjali Mahajan; Vijay Barwal; Priyanka Gautam; Saurabh Rattan; Shaina Chamotra

doi:10.4103/cjhr.cjhr_130_18

ORIGINAL ARTICLE

Year : 2019 | Volume : 6 | Issue : 2 | Page : 93-96

Kayakalp – Utility of a novel Indian tool for the assessment of biomedical waste management in a district hospital of Northern India

Ankit Chaudhary¹, Anjali Mahajan¹, Vijay Barwal¹, Priyanka Gautam¹, Saurabh Rattan¹, Shaina Chamotra²
¹ Department of Community Medicine, IGMC, Shimla, Himachal Pradesh, India
² Department of Obstetrics and Gynaecology, IGMC, Shimla, Himachal Pradesh, India

Date of Submission	31-Aug-2018
Date of Decision	04-Sep-2018
Date of Acceptance	16-Oct-2018
Date of Web Publication	23-May-2019

Correspondence Address:
Anjali Mahajan
Department of Community Medicine, IGMC, Shimla, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cjhr.cjhr_130_18

Abstract

Introduction: Kayakalp is an innovative initiative launched by the Ministry of Health and Family Welfare as a part of the Swachh Bharat Abhiyan campaign. The primary objective of this venture is the promotion of cleanliness and delivery of quality health-care services through public health facilities in India. This standardized tool was used to evaluate six key parameters of hospital management of a district hospital in northern India. In this study, we present findings of biomedical waste (BMW) management assessment, one of the six assessment domains of the tool. Methods: A cross-sectional observational study was done using Kayakalp assessment tool in a district hospital of a north Indian state in the year 2015. Methods used to assess facility were direct observation, staff interviews, and review of documents. Results were recorded as full, partial, and no compliance for the domain of waste management. Results: The total score for BMW management as per Kayakalp tool was 82 (out of a maximum of 100), with mean score of 8.2 and standard deviation ± 1.48. Overall, there were ten criteria (C1 to C10). The scores were excellent, i.e., 100% for disposal of BMW, solid general waste, and liquid waste management. Minimum score of 60% was seen in the area of sharps management. Conclusion: The standardized approach of the evaluation of public health facilities through Kayakalp tool would help in judging their performance on a uniform pedestal. Such model tools after adjustment to local needs can also be adopted by other nations for the assessment of their health services.

Keywords: Biomedical waste management, district hospital, Kayakalp

How to cite this article:
Chaudhary A, Mahajan A, Barwal V, Gautam P, Rattan S, Chamotra S. Kayakalp – Utility of a novel Indian tool for the assessment of biomedical waste management in a district hospital of Northern India. CHRISMED J Health Res 2019;6:93-6

How to cite this URL:
Chaudhary A, Mahajan A, Barwal V, Gautam P, Rattan S, Chamotra S. Kayakalp – Utility of a novel Indian tool for the assessment of biomedical waste management in a district hospital of Northern India. CHRISMED J Health Res [serial online] 2019 [cited 2023 Mar 28];6:93-6. Available from: https://www.cjhr.org/text.asp?2019/6/2/93/258970

Introduction

Health-care institution is an organization where health services are utilized by people of diverse age, gender, socioeconomic status, and ethnicity.^[1] “Kayakalp” initiative is as a part of Swachh Bharat Abhiyan campaign was launched by the Ministry of Health and Family Welfare on May 15, 2015. This innovative venture aims at quality improvement in public health-care facilities through emphasis on six key parameters, namely, (1) hospital/facility upkeep, (2) sanitation and hygiene, (3) waste management, (4) infection control, (5) support services, and (6) hygiene promotion. This initiative aims to boost the functioning of public health-care facilities by incentivizing and providing cash awards to the facilities that demonstrate high level of compliance to the above parameters.^[2]

One of the key components of “Kayakalp” assessment is health-care waste management. The present study aimed at assessing the quality of biomedical waste (BMW) management in the district hospital of northern India using the standard Kayakalp tool.

Methods

A cross-sectional study was done using the “Kayakalp” assessment tool in a district hospital in northern state in the year 2015. This tool has a standardized protocol, and scoring for various parameters is done utilizing assessment checklists prepared for quality assessment. Methods used to assess the facility were direct observation, staff interview, and review of the documents.

For deciding and giving the awards to those facilities that perform well under this initiative, a State level Award Committee has been constituted under the chairpersonship of the Health Secretary/Mission Director. External assessment teams have been constituted and trained by the National Institute of Health and Family Welfare, India, and the National Health Systems Resource Centre for the proposed assessment and validation of the scores of nominated facilities.

Being a part of the external assessment team, the researcher assessed and validated scores of the nominated district hospital. After the framing of Kayakalp awards guidelines, this was the first time such an activity was being undertaken to choose the top performing health facilities for these awards.

In this study, we present the findings of a BMW management assessment, one of the six assessment domains of the tool. Scoring was done as fully compliant (2), partially complaint (1), and non-compliant (0). It was done as per the guidelines and checklist provided by the Kayakalp program. In this tool, there are ten criteria for the assessment of BMW management (C1–C10), each having a maximum score of 10. Therefore, the maximum total score for this domain is 100.

Data were entered in Microsoft Excel 2007 and analyzed using Epi Info version 7.2. Student's t-test was used to compare the mean scores obtained in the present study, and the results obtained from a similar study conducted in Southern India. Ethical approval for conducting study was obtained from the Institutional Ethics Committee.

Operational definition of BMW was taken as “any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or research activities pertaining thereto or in the production or testing of biological or in health camps, including the categories mentioned in schedule I of the Government of India's BMW (Management and Handling) Rules 2016.”^[3]

Results

The total score for BMW management as per the “Kayakalp” tool was 82 (out of a maximum of 100), with a mean score of 8.2 and standard deviation ± 1.476. Overall, there were ten criteria (C1 to C10). The scores were excellent, i.e., 100% for disposal of BMW, solid general waste, and liquid waste management. Minimum score of 60% was seen in the area of sharps management [Table 1].

Table 1: Aggregate scores of various criteria of biomedical waste management

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Comparison of scores between north and south Indian hospitals

Based on the standardized Kayakalp tool, we compared scores for the BMW management among two district hospitals of north and south India. The performance of north Indian hospital was found to be better in the areas of segregation, disposal, management of solid and liquid waste, and area of equipment and supplies for BMW management. However, the management of sharps was better in the southern hospital.^[4]

The mean score of BMW management in the South Indian District Hospital (6.40 ± 1.713) was lower as compared to those of the North Indian hospital (8.20 ± 1.476) with a statistically significant (P < 0.02) mean difference of 1.80 (95% CI: 0.29–3.30) [Table 2].

Table 2: Comparative scores of Kayakalp assessment on biomedical waste management of the two district hospitals

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Discussion

Understanding human health with all its complex dimensions is a challenging task. As there are rapid advances in science and technology, its impact on health and life sciences cannot be ignored. Globally, the provision of quality health-care services is a matter of utmost priority and herein lies the significance of public health-care institutions. Efficient BMW management system in any health facility is of utmost importance. BMW is a potential hazard to the public health as well as the environment. While fulfilling the objective of tackling health problems, eliminating potential risks and treating sickness, health-care institutions inevitably create waste which if inadequately and inappropriately handled, may have serious health consequences and adverse impact on the environment.^[5]

This tool ensures none of the steps of BMW management from generation to disposal are overlooked or undermined. As per the Kayakalp tool, the total score of the hospital for BMW domain was 82%. Complete segregation of BMW at the point of generation is the backbone of BMW management. Even though the scores of segregation were high (90%), nothing short of 100% is acceptable as even slight mixing of the infectious waste will render whole of the hospital waste as hazardous. Most of the criteria were met like waste segregation in different color-coded bins, general and infectious waste was not mixed, and the staff was aware of segregation protocols, but work instructions for segregation and handling of BMW were not displayed at all the points of use. Similar findings were seen in Romania where proper segregation was practiced, and appropriate containers and color coding was done.^[6]

Contrary to these findings, in various other studies like one done in Yemen, no segregation was seen; segregation was only 21.4% in Nigeria, 60% in Palestine study, in Jhansi only 43%, and in Puducherry, only 12% waste was segregated.^{[7],[8],[9],[10],[11]} In another study by Patan et al., color coding was not practiced; while in a study conducted in Nigeria, only 2.8% waste was disposed in color-coded bins.^[8],[12]

The observed low score (70%) for collection and transport of biomedical was due to improper time schedule (at least twice a day) for collection of BMW, nonusage of closed containers for transportation, and no provision of “dirty corridors” for waste transportation which are not used by patients and visitors routes. However, it was seen that the waste bins were properly covered and not overfilled, i.e., less than two-thirds of the bin capacity. Similar findings were seen in a study done in Bareilly, UP, while in Puducherry study, 84% of the waste was transported in open containers and trolleys.^[11],[13]

The sharps management was inadequate with a score of 60%. It was observed that the needle cutters were being used and sharps were being put in disinfectant solution (1% chlorine) before disposal. Safe methods (sieves and puncture proof containers) were not available for processing and transport of sharps. Hospital staff had little/no knowledge of postexposure prophylaxis (PEP). Although the PEP kit was available, the protocol was not prominently displayed at workstations in the facility. Similarly, only 30% waste handlers (sweepers) were aware of risks in Bareilly, UP study and in Yemen also, only 20% sharps waste was sorted.^[7],[13]

The scores for disposal of BMW, solid general waste management, and liquid waste management were excellent at 100%. There was a valid contract with the common BMW treatment facility (CBMWTF), and plastic waste was adequately disinfected and mutilated before disposal. There were separate bins for recyclable and biodegradable general waste and were disposed through the municipal waste management system. General and infectious waste was not mixed, and it was removed daily by the municipal corporation. Laboratory samples, body fluids, and infectious liquid waste were adequately treated with chlorine solution before disposal in the sewage line.

On the other hand, 80% score was observed for storage of BMW. A dedicated room for storage of BMW was available. It was secured and away from the patient area, and it was handed over to the CBMWTF every alternate day. The only drawback was that biohazard signs were not displayed at the storage sites.

The management of hazardous waste was also good at 80%, with the deficiency only seen in the disposal of disinfectant solution and laboratory reagents, which were being drained untreated into the sewage. The staff was aware of the mercury spill management, and the mercury spill management kit was readily available. Similar findings were seen in a Romanian study where decontamination of BMW before disposal was done properly. Contrary to this in Nigeria, no pretreatment of liquid or soiled waste was done, while in Yemen, only 20% solid waste was treated and no treatment of liquid waste was done, and the study found that there were no places for temporary storage of BMW.^[7],[8]

The scores for the subdomain of equipment and supplies for BMW management were satisfactory at 70%. There was sufficient availability of bins at the waste generation points for the BMW as well as the general waste, along with the adequate number of trolleys for collection and transportation of waste. However, the facility lacked in the availability of needle and hub cutters, puncture-proof containers at each point. Similarly, the supply of color-coded chlorine-free liners was not adequate. Similar deficiency of needle cutters was seen in studies conducted at Ludhiana, Puducherry (79% deficiency), and Yemen (70% deficiency).^{[7],[11],[14]}

About 80% of scores were observed for statutory compliances. The facility had a valid authorization from the State Pollution Control Board, and the annual report on BMW management was being submitted annually to the Board. Records of waste generation were well maintained, and there was a designated person was for the monitoring of BMW management in the facility. The only deficiency identified for this subdomain was nonavailability of the copy of BMW rules in the facility. This was in contrast to a study conducted in Nigeria, where no records/registers were maintained.^[8]

This study has few limitations too. First, Kayakalp is a new initiative, and it was done as a pilot study. Hence, there is not enough published literature available for comparison of the assessment in various public health facilities.

Second, the assessment of the two hospitals has been done by two different teams, so some subjective bias may have come in the scoring.

Conclusion

There is a need for the evolution of health-care institutions so that they can keep up with the ever-evolving health-care needs of the community. Policies and programs have to be framed and implemented for setting and attaining benchmarks for the standards of performance of the health facility. Kayakalp is one such novel venture undertaken by the Government of India to encourage cleanliness, promote hygiene and sanitation, and ensure adoption of infection control practices. Kayakalp as a part of Swachh Bharat Abhiyan is a remarkable initiative by the Government of India. After its implementation, a visible change has been seen in the cleanliness and hygiene of the hospitals. The incentivized approach and periodic checking by peer and then external evaluation teams have also led the hospital administration to be continuously on their toes for the regular upkeep and maintenance of the facility. This approach of incentivization and appreciation would result in better outcomes in comparison to the strategy of direct provision of funds for the same. As this initiative has been launched nationwide, all the public health-care facilities can be judged utilizing the same criteria and at the same level. A healthy competition among facilities will lead to better delivery of quality health services.

Besides this, periodic sensitization programs for the health-care personnel for effective BMW management practices implementation with a special focus on recent amendments should be mandatorily incorporated into their work schedule.

To summarize, “Kayakalp,” an Indian innovation, can be adapted and replicated in other settings also for quality assessment of the health-care facilities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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