UNDP GEF Project on Global healthcare Waste
INSTRUCTOR GUIDE
MODULE 23: MANAGEMENT OF HEALTHCARE WASTEWATER
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UNDP GEF Project on Global healthcare Waste
MODULE 23: MANAGEMENT OF HEALTHCARE WASTEWATER
Estimated Time
Module Overview
Learning Objectives
Target Audience
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Instructor Preparation
Materials Needed
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Lecture: 30 minutes
Activity- discuss homework: 30 minutes
Describe sources of wastewater in a healthcare facility
Describe characteristics and hazards associated with wastewater from healthcare
facilities
Describe treatment and disposal options for wastewater from healthcare facilities
Identify sources and hazards of wastewater in your healthcare facility
Identify appropriate methods collection, treatment and disposal of wastewater
Describe your facility’s wastewater management program
Discuss possible options to improve management of waste water in your facility
HCWM coordinators
Facility managers
Environmental officer, environmental compliance officer, or other relevant
management staff
Facility engineering staff
Environmental health officials, sanitation engineers, or other local government
officials in charge of wastewater discharges from healthcare facilities
Make notes pages of PowerPoint slides to hand out to class
Make copies of class exercise for distribution after PowerPoint presentation
Read Chapter 9 in Blue Book, and other materials included in the References
Make copies of any additional documents/readings that may be handed out to class,
such as those included in the References
Prepare any additional notes to be discussed during the presentation
Prepare any additional discussion points or review questions
Projector
Student handouts: slides, exercise, homework
Flip chart and marker pens and/or board and chalk
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UNDP GEF Project on Global healthcare Waste
Student Preparation
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Review Questions
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Blue Book Chapter 9
Obtain information about what happens to the wastewater from your healthcare
facility, obtain copies of your facility’s wastewater discharge permit if any as well as
any wastewater test results, and complete your homework.
What are some major sources of wastewater within your healthcare facility? What
about minor sources?
What are some public and environmental health hazards associated with healthcare
wastewater? Are there certain hazards you perceive within your own facility?
What happens to the wastewater in your facility after it goes down the drain? What
procedures does your facility use in the overall management of wastewater and
other hazardous liquid wastes? What safety measures are in place? Does the
facility use waste minimization techniques to limit the amount of discharged
liquids?
Does your facility have wastewater treatment on-site? If not, what pre-treatment
methods are used, if any, before release to the main municipal sewer system? Are
septic tanks and cesspools used?
What are the country/region-specific regulations and guidelines for managing
wastewater (segregation, treatment, disposal, etc.) from healthcare facilities?
Discuss some ways to minimize wastewater in your facility.
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UNDP GEF Project on Global healthcare Waste
PRESENTATION
Slide Number/Title
Teacher’s Notes
Slide 1: Title Slide
Slide 2: Module Overview
Introduce the outline and major points of the presentation
Slide 3: Learning Objectives
Describe what participants will learn at the end of this module.
Slide 4: Healthcare
Wastewater
Slide 5: Categories of
Healthcare Wastewater
Go over the main characteristics of healthcare wastewater
Slide 6: Sources of Healthcare
Wastewater
Go over the main sources of wastewater in a healthcare facility. Below are descriptions of
each source from the Blue Book.
Healthcare wastewater can be divided into 3 main categories:
-blackwater
-greywater
-stormwater
Administration and wards generate wastewater, comparable to domestic wastewater. The
urine of patients from some wards (surgery wards, oncology, infectious disease ward, etc.)
might contain higher amounts of antibiotics, cytotoxic and X-ray contrast media. Additionally,
higher amounts of disinfectants may occur.
Kitchens of hospitals often generate the most polluted wastewater stream as it contains
leftovers, waste from food processing, and high rates of disinfectants and detergents. Starch,
grease, oil and the high organic content might create problems during the wastewater
management.
The laundry is the place with the highest quantity of produced grey wastewater. The
wastewater often is hot, has a high pH (alkaline) and might contain high rates of phosphate
and AOX (absorbable organically bound halogens) if chlorine-based disinfectants are used.
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UNDP GEF Project on Global healthcare Waste
Operating theatres and ICUs generate wastewater with high contents of disinfectants
(glutaraldehyde), detergents, and pharmaceuticals. Additionally the organic content can be
high due to the disposal of body fluids and rinsing liquids.
Laboratories are a possible source for chemicals in the wastewater stream. Of particular
relevance are halogenated and organic solvents, colorants from histology and haematology
(Gram staining), cyanides (haematology) and formaldehyde and xylene (pathology).
The radiology department is the main generator of photochemicals (developing and fixing
solutions) in wastewater and potentially contaminated rinsing water.
Haemodialysis requires the disinfection of the dialysers and sometimes the used filters.
Accordingly, the disinfectant content in the wastewater can be high.
Dental departments might contaminate the wastewater with mercury (amalgam) if no
amalgam separators are installed in the sink waste pipe system.
Central sterile supply departments are major consumers of disinfection solutions, including
aldehyde-based solutions.
Slide 7: Health and
Environmental Hazards of
Healthcare Wastewater
Slide 8: Health and
Environmental Hazards of
Wastewater
Go through the list of important wastewater contaminants
It is important that healthcare wastewater is given the same consideration and precautions
that is given to domestic wastewater as being potentially infectious. In fact, a portion of the
wastewater from the healthcare facility will pose a higher risk than domestic wastewater.
The wastewater might contain chemicals, pharmaceuticals, contagious biological agents, and
possibly radioisotopes. Sewers of healthcare establishments are often not watertight and a
significant amount of the wastewater may leak into the groundwater. Hospitals are frequently
not connected to efficient working sewage treatment plants and, in some cases, municipal
sewer networks may not even exist.
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UNDP GEF Project on Global healthcare Waste
Slide 9: Health and
Environmental Hazards of
Wastewater
Describe the environmental implications of wastewater and some of the diseases associated
with its improper management. There may be diseases endemic to your region that you
would like to mention or share statistics about the death toll from water-borne and vectorborne diseases in your country/region.
Improper management, collection, treatment and disposal of wastewater and/or sludge will
result in the pollution of local water sources with pathogens. This can cause numerous waterborne diseases and vector-borne diseases (e.g. malaria and dengue fever by providing
breeding place to the vectors) and promotes the spreading of parasites (e.g. roundworms or
Ascaris lumbricoides). Nitrates in the groundwater from untreated wastewater can result in
methaemoglobinaemia (disorder in which there is a higher than normal level of
methemoglobin – an oxidized form of haemoglobin in the blood that leads to an insufficient
amount of oxygen being released to body tissues). Waterborne diseases are one of the biggest
threats to human life, especially in developing countries.
Slide 10: Wastewater
Management
The basic principle of effective wastewater management is to strictly limit the amount of
hazardous liquids discharged to sewers.
Slide 11: Wastewater
Management
Review earlier modules for general principles of healthcare waste management (segregation,
collection, storage, etc.), if needed.
Central system: typically, a system of linked sewer pipes will form a sewerage system that
collects wastewater from around the healthcare facility that is carried below ground and
channelled to a central location for treatment or disposal.
Decentralized system: where a main sewerage system has not been constructed, wastewater
can be collected from medical areas by pipe systems and passed into septic tanks or cesspools.
The wastewater is then removed periodically from the pits by a tanker fitted with a sludge
pump and then taken for treatment and disposal. This is not the preferred approach for
healthcare facilities.
It is generally not recommended to separately collect grey- and blackwater, because of
possible hydraulic problems. Storm water or rainwater can be collected separately and used
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UNDP GEF Project on Global healthcare Waste
for purposes that do not require highly treated water, such as toilet flushing or washing
vehicles.
Slide 12: Wastewater
Management
Slide 13: Pre-treatment of
Hazardous Liquids
Describe pre-treatment and when/how it should be used.
Collected body fluids, small quantities of blood and rinsing liquids from the OR and the ICU
can be discharged in the sewer system without pre-treatment if the patient is not suffering
from an infectious disease; otherwise, it shall be first disinfected, preferably with a thermal
method. Larger amounts of blood should not be emptied in the sewer, as this will result in
blockages, and should instead be disposed of as pathological waste. However, blood can be
disposed of directly to a septic tank system if proper safety measures are followed.
Slide 14: Pre-treatment of
Hazardous Liquids
Slide 15: Liquids That Do Not
Require Pre-Treatment
Slide 16: Healthcare Sewage
System
Slide 17: Healthcare Sewage
System
Slide 18: On-Site Wastewater
Treatment for Large
Healthcare Facilities
Describe the preferred set-up for a healthcare facility sewage system.
Discharging wastewater generated from the healthcare facility into the municipal sewage
system is a preferred method if there is adequate pre-treatment and the sewage plant
treatment plant fulfills any local regulatory requirements.
Typically, wastewater treatment involves three stages. The first stage is the removal of solids,
which are separated by sedimentation (primary treatment). Then dissolved biological matter
is progressively converted into a solid mass by using indigenous, water-borne bacteria. Some
ingredients will be eliminated by adsorption to the sludge, which will separated by
sedimentation afterwards (secondary treatment). At the end, solid and liquid materials are
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UNDP GEF Project on Global healthcare Waste
separated and the treated water may be further treated to remove suspended solids,
phosphates or other chemical contaminants; or it may be disinfected (tertiary treatment).
Chlorine is commonly used as the disinfectant in tertiary treatment of healthcare wastewater.
Its effectiveness will depend upon a number of water quality parameters of the water being
treated (pH, turbidity, etc.). It will only be effective if the wastewater contains less than
10mg/L of suspended organic matter.
Slide 19: Example of On-Site
Wastewater Treatment for a
Large Healthcare Facility
Slide 20: On-Site Wastewater
Treatment
Slide 21: On-Site Wastewater
Treatment
Slide 22: Minimum Approach
to Wastewater Management
On-site treatment of hospital sewage will produce a sludge that contains high concentrations
of helminths (parasitic worms) and other pathogens and therefore must be treated prior to
disposal. The most common treatment options include anaerobic digestion, aerobic digestion,
composting, and reed beds.
Important parameters for monitoring effluent water quality
Describe the WHO’s recommendations for a minimal sanitation system within the healthcare
facility.
Treatment and disposal at off-site specialized treatment plants for hazardous wastes should
be in accordance with national standards or international conventions, such as the Basel or
Stockholm conventions.
Slide 23: Minimum Approach
to Wastewater Management
Slide 24: Minimum Approach
to a Liquid Hazardous Waste
Management System
In the next three slides inclusive, go through the important elements of a minimal liquid
hazardous waste management system, as laid out in the Blue Book. Many countries do not
have the means or access to follow the ideal guidelines, so this approach highlights the most
important aspects that they should prioritize when dealing with wastewater.
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UNDP GEF Project on Global healthcare Waste
Slide 25: Minimum Approach
to a Liquid Hazardous Waste
Management System
Slide 26: Minimum Approach
to a Liquid Hazardous Waste
Management System
Slide 27: New technology
Slide 28: National and local
regulations related to
wastewater discharges
Slide 29-30: Discussion
References (in order as they
appear in slides)
Ask participants if they are aware of any new technology available in their country. Or
instructor may include some recent country specific information here.
Add information on any national and/or local regulations related to wastewater discharges
from healthcare facilities, including effluent limits if any.
Generate a class discussion about the major topics from the presentation
Blue Book Chapter 9
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UNDP GEF Project on Global healthcare Waste
ACTIVITY: MODULE 23: HOMEWORK (30 MINUTES)
The purpose of this activity is for participants to outline the wastewater management strategies at their facility and discuss
ways to minimize wastewater.
Instructor: Provide the class with the homework prior to the session. Break class into groups of three or more. Participants
will discuss their home work in groups and then present their answers during the de-brief.
MODULE 23 HOMEWORK: MANAGEMENT OF WASTEWATER
All participants will need to:
1. Obtain information about what happens to the wastewater from his or her healthcare facility.
2. Obtain copies of their facility’s wastewater discharge permits if any and understand what the permits mean.
(Discussion: Has the facility conducted tests of its wastewater? If so, how do the test results compare with the discharge
limits in the permit? What wastewater pollutants need to be reduced if any?)
3. Discuss how they could improve wastewater collection and disposal in his or her healthcare facility.
4. Discuss wastewater minimization techniques.
De-brief
Instructor will de-brief the homework after group discussion.
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