Şehir hastanelerinde atık yönetimi ve COVİD-19'un hastanelerde atık miktarı ve dağılımına etkisinin incelenmesi
Waste management in city hospitals and examining the effect of COVİD-19 on waste amount and distribution in hospitals
Yazar: MERVE KONCAGÜL
Danışman: PROF. DR. OSMAN ATİLLA ARIKAN
İstanbul Teknik Üniversitesi / Lisansüstü Eğitim Enstitüsü / Çevre Mühendisliği Ana Bilim Dalı / Çevre Bilimleri, Mühendisliği ve Yönetimi Bilim Dalı
Derece: Yüksek Lisans, 2021
Konu: Çevre Mühendisliği = Environmental Engineering
Dizin: Sıfır atık = Zero waste ; Tıbbi atık = Medical waste ; Şehir hastaneleri = City hospital

Özet:
Artan nüfus ve kentleşme, toplumların refah seviyesinin yükselmesi, gelişen teknolojiler, satın alma gücündeki artış, artan tüketim alışkanlıkları, davranışları, hizmette lüks ve kalite arayışı atık miktarının artmasına sebep olmaktadır. Bu çalışmada şehir hastanelerindeki atıkların kaynağında ayrı toplanması ve azaltılması stratejilerine uygun olarak yapılan atık yönetimi ve Covid-19'un hastanelerde atık miktarı ve dağılımına etkisi incelenmiştir.
Bu çalışmada bir adet şehir hastanesinde atık yönetiminin incelenmesi yapılmış, altı adet şehir hastanesinde Covid-19'un atık miktarlarına ve dağılımına etkisini incelmek için Covid-19'un ülkemizde ilk görüldüğü  yıl olan 2020 yılı verileri ile önceki yıllara ait veriler karşılaştırılmıştır.
Çalışma yapılan Tekirdağ İsmail Fehmi Cumalıoğlu Şehir Hastanesinde atıkların oluştuğu andan bertaraf edilmesine kadar hastanede izlediği süreç incelenmiştir. Hastanede evsel, ambalaj ve tıbbi atıklar 40 L ve 65 L'lik konteynerlerde, tehlikeli atıklar 30 L ve 60 L'lik mavi varillerde ayrı olarak toplanıp, katlardaki 240 L konteynerlerin yer aldığı atık odalarına taşınmaktadır. Atık taşıma asansörü ve koridorundan geçirilen atıkların tartımı yapılıp kayıt altına alınmaktadır. Tartım ve kayıt işlemi tamamlanan atıklar geçici depolama alanına götürülmekte ve uygun atık taşıma araçlarına verilmektedir. İncelenen hastanede atıkların kaynağında ayrıştırıldığı, toplandığı, depolandığı ve atık yönetiminin başarılı bir şekilde  uygulandığı görülmüştür. 
Çalışma yapılan altı adet şehir hastanesinde (Isparta, Manisa, Yozgat, Elazığ Fethi Sekin, Kayseri, Ankara Bilkent) Covid-19 öncesi (2019 yılı) ve sonrası (2020 yılı) tıbbi atık miktarları incelenmiş, sadece üçünde (Isparta, Manisa, Yozgat) evsel, ambalaj ve tehlikeli atık miktarlarına da bakılmıştır.
Evsel atık miktarları (ambalaj atığı hariç) Covid-19 öncesi (2019) 2,94-3,53 kg/yatak.gün arasında değişirken, Covid-19 sonrası (2020) 1,76-3,16 kg/yatak.gün değerlerine (Isparta'da %28,2, Manisa'da %1,6, Yozgat'ta %50,1) azalmıştır. Atık oluşumunun en fazla görüldüğü birim yemekhane  olmuştur. 
Ambalaj atığı miktarları Covid-19 öncesi 0,63-0,72 kg/yatak.gün arasında değişirken, Covid-19 sonrası 0,44-0,67 kg/yatak.gün aralığında değişmiştir. Ambalaj atıkları, Covid-19 sonrası evsel atıklara benzer şekilde (Isparta'da %23,6, Yozgat'ta %30,2) azalmıştır. Sadece Manisa'da %3,1 artış olmuştur. Ambalaj atıklarının en fazla oluştuğu birim evsel atıklara benzer şekilde yemekhane  olmuştur.
Tehlikeli atıklar Covid-19 öncesi 0,05-0,21 kg/yatak.gün arasında değişirken, Covid-19 sonrası (2020) 0,16-0,21 kg/yatak.gün aralığında değişmiştir. Tehlikeli atıklar, Covid-19 sonrası (Isparta'da %50, Yozgat'ta %220, Manisa'da %1) artmıştır. Tehlikeli atıkların oluştuğu birimler açısından hastanelerde benzer bir eğilim bulunmamaktadır. Tehlikeli atıklar 2019 ve 2020'de ağırlıklı olarak teknik birim, laboratuvar ve yoğun bakımdan oluşmuş, bununla birlikte 2020 yılında Covid-19 ve göğüs hastalıkları servislerinden de ciddi oranda tehlikeli atık kaynaklandığı gözlenmiştir.
Tıbbı atık miktarları Covid-19 öncesi 0,80-1,36 kg/yatak.gün arasında değişirken, Covid-19 sonrası 0,96-1,91 kg/yatak.gün değerlerine (Isparta'da %8,1, Yozgat'ta %31,1, Manisa'da %72,1, Elazığ'da %20 ve Kayseri'de %69,1) artmıştır. Tıbbi atıklar 2019 yılında ağırlıklı olarak yoğun bakımdan kaynaklanmış, ameliyathaneden de önemli oranda tıbbi atık oluşmuştur. 2020 yılında en fazla tıbbi atık 2019'a benzer şekilde yoğun bakımdan gözlenmiş, Covid-19 biriminden de ciddi oranda tıbbi atık kaynaklanmıştır. İncelenen şehir hastanelerindeki 2019 yılı tıbbi atık üretimi ortalaması 1,11 kg/yatak.gün olup, bu değer Türkiye'de Sağlık Bakanlığına bağlı hastanelerin ortalaması olan 1,73 kg/yatak.gün'den düşüktür.  
Bu çalışmada yatak başına atık verileri karşılaştırılmış olup, hastanelerdeki yatak doluluk oranları değişebildiğinden değerlendirmede hatalar olabilmektedir. Hasta başına atık verileri değerlendirme yapmak için daha uygun olup, bu çalışmada hasta sayıları bilgilerine ulaşılamamıştır. Sonraki çalışmalarda hasta başına atık verilerinin de hesaplanması önerilmektedir.

Abstract:
Increasing population and urbanization, welfare level of societies, developing technologies, purchasing power, consumption habits and behaviors cause the amount of waste to increase. This situation disrupts the ecological balance of the world and increases the stress on natural resources. This situation creates the necessity of sustainable and integrated management of wastes. Waste is produced by human activity. Proper management of waste is important for building sustainable and liveable cities. But it remains a challenge for many developing countries and cities. Waste management is intended to reduce the adverse effects of waste on human health, the environment, planetary resources and aesthetics. Waste management is an approach and discipline that evaluates waste generation, aims to minimize raw material extraction and to maximize resource efficiency. Besides, waste is transformed into another product through recycling, recovery, reuse to meet another objective in sustainable waste management. Zero waste is a waste prevention approach. It aims to ensure the efficient use of natural resources, to prevent waste, to reduce the amount of waste generated, to separate the wastes at the source, and to add value to the economy with the recovery and recycling of wastes. The zero waste project is aimed to establish a waste management system in public institutions and organizations, private sectors, municipalities, hospitals, airports, organized industrial zones, market places, education and tourism campuses, apartments, city squares, plazas, shopping centers.
According to the Waste Management hierarchy, first of all, waste generation should be prevented. The second step is to reduce the generation of waste. The reuse of the resulting waste is the third step. The fourth and fifth steps are recycling and energy recovery. Waste disposal should be preferred as the last option. The circular economy, which is an understanding that takes the sustainable development as a role model, where wastes are re-used, that ensures the waste generated as a result of production or consumption is returned to the economy, and that circulates cyclically by prolonging the life span of the wastes in order to prevent waste instead of a buy-consume-disposal approach, aims to make a profit by using the waste.
While the resulting wastes pose a threat to the nature, ecosystem and all living things, the medical wastes from the hospitals also pose a threat to human and environmental health. Waste from hospitals includes all types of waste. The wastes coming out of the hospitals should be of medical, hazardous and domestic nature, and these wastes should be collected, transported and disposed of by avoiding contact with each other. Wastes generated as a result of health activities are generally variable in terms of quantity and waste types and characteristics vary according to the branches in hospitals. It is essential to have waste management in hospitals in order to minimize human health risks and reduce economic costs for health institutions. Medical wastes generated in hospitals threaten the environment and human health because they carry disease-causing microorganisms, spread and contaminate them. Disposal of medical wastes is extremely important for the health and safety of everyone working in healthcare facilities. For this reason, the management of medical wastes generated in hospitals should be established in a way that covers every stage of the waste from generation to disposal. The fact that waste activities in hospitals are not interrupted and continue cyclically depends on having a good waste management system.
Covid-19 is a virus that emerged in Wuhan, China in December 2019, and the first case in Turkey was recorded in March 2020, developing without a specific reason and spreading rapidly from person to person. While the coronavirus affected millions of people, some succumbed to this disease, while others completed their treatment in the hospital or at home and regained their health. Pandemic services have been established for Covid-19 patients in state, private and city hospitals. The rapidly spreading and contagious Covid-19 epidemic has increased the use of face masks, gloves, visors, protective gowns and gloves, disposable plastics, takeaway food containers and packaging worldwide. The Covid-19 pandemic has increased the burden of medical waste, especially in hospitals. 
In this study, the general characteristics of health care wastes and the classification of wastes, waste management in accordance with the separate collection and reduction strategies of waste at the source in city hospitals, and the effect of Covid-19 on the amount and distribution of waste in hospitals were examined.
In this study, waste management was examined in one city hospital, and in order to examine the effect of Covid-19 on waste amounts and distribution in six city hospitals, the data of 2020, the year Covid-19 emerged in our country, and the data before it was compared.
In Tekirdağ İsmail Fehmi Cumalıoğlu City Hospital, where the study was conducted, the way the wastes taken in the hospital from the moment they were generated to their disposal was examined. In the hospital, domestic, packaging and medical wastes are collected in 40 L and 65 L containers, and hazardous wastes are collected separately in 30 L and 60 L blue barrels and transported to the waste rooms where 240 L containers are located on the floors. The wastes passed through the waste transport elevator and corridor are weighed and recorded. The wastes whose weighing and recording processes are completed are taken to the temporary storage area and given to the appropriate waste transportation vehicles. It was observed that the wastes were separated at the source, collected, stored and waste management was successfully implemented in the hospital examined.
The amount of medical waste before (2019) and after (2020) Covid-19 was examined in six city hospitals (Isparta, Manisa, Yozgat, Elazığ Fethi Sekin, Kayseri, Ankara Bilkent). All waste types were examined in only three (Isparta, Manisa, Yozgat).
The amount of domestic waste (excluding packaging waste) varied between 2.94-3.53 kg/bed.day before Covid-19 (2019). It decreased to 1.76-3.16 kg/bed.day after Covid-19 (2020). (28.2% in Isparta, 1.6% in Manisa, 50.1% in Yozgat). The maximum household waste generation was observed in the cafeteria. 
The amount of packaging waste varied between 0.63-0.72 kg/bed.day before Covid-19, it changed between 0.44-0.67 kg/bed.day after Covid-19. Packaging wastes decreased (23.6% in Isparta, 30.2% in Yozgat) after Covid-19, similar to household waste. There was an increase of 3.1% only in Manisa. The maximum packaging waste generation was observed in cafeteria, similar to domestic wastes.
Hazardous wastes varied between 0.05-0.21 kg/bed.day before Covid-19. It changed between 0.16-0.21 kg/bed.day after Covid-19 (2020). Hazardous wastes increased after Covid-19 (50% in Isparta, 220% in Yozgat, 1% in Manisa). There is no similar trend in hospitals in terms of units where hazardous waste is generated. Hazardous wastes mainly consisted of technical units, laboratories and intensive care units in 2019 and 2020, however, in 2020, it was observed that a serious amount of hazardous waste was generated from Covid-19 and chest diseases services.
The amount of medical waste varied between 0.80-1.36 kg/bed.day before Covid-19. It decreased to 0.96-1.91 kg/bed.day after Covid-19 (8.1% in Isparta, 1 in Yozgat). It increased by 31.1% in Manisa, 72.1% in Manisa, 20% in Elazig and 69.1% in Kayseri. Medical wastes mainly originated from intensive care in 2019, and a significant amount of medical waste was generated from the operating room. In 2020, the most medical waste was observed in intensive care, similar to 2019, and a serious amount of medical waste was sourced from the Covid-19 unit. The average of 2019 medical waste production in the examined city hospitals is 1.11 kg/bed.day, which is lower than 1.73 kg/bed.day, which is the average of hospitals affiliated to the Ministry of Health in Turkey.
The total amount of waste varied between 5.18-5.69 kg/bed.day before Covid-19. It changed between 4.16-5.92 kg/bed.day after Covid-19. Total waste amounts decreased in Isparta (16%) and Yozgat (26.9%), and increased in Manisa City Hospital (17.5%). The decrease in the total amount of waste resulted from the decrease in domestic and packaging wastes.
In this study, waste data per bed were compared, and since bed occupancy rates in hospitals can change, there may be errors in the evaluation. Waste data per patient is more suitable for evaluation, and information on the number of patients could not be reached in this study. It is recommended to calculate waste data per patient in future studies.