Sharps injuries in healthcare waste handlers.

Clinical waste disposal carries with it a risk of serious and possibly life-threatening infection. Combining confidential questionnaires and structured interviews with discrete observation, the attitudes and approach to safe handling of bulk clinical wastes by staff in a specialist waste treatment facility were assessed. With particular attention to glove use and hand hygiene, observations were supplemented by review of group-wide accident and incident records, with emphasis on sharps injuries and related blood and bloodstained body fluid exposures. Deficiencies in glove selection and use, and in hand hygiene, were noted despite extensive and on-going training and supervision of waste handlers. Though ballistic puncture-resistant gloves protect against sharps injury, these were uncomfortable in use and were sometimes rejected by waste handlers who preferred thin-walled nitrile gloves that were more comfortable in use though provide no resistance to penetrating injury. Among the waste handlers working for a single specialist waste disposal company, sharps injuries (n = 40) occurred at a rate of approximately 1 per 29 000 man hours. Injuries were caused by hypodermic needles from improperly closed or overfilled sharps boxes (n = 6) or from sharps incorrectly discarded into thin-walled plastic sacks intended only for soft wastes (n = 34). Most injuries occurred to the fingers or hands. No seroconversions occurred, though two individuals suffered anxiety/stress disorder necessitating prolonged leave of absence with professional counselling and support. Glove use and hand hygiene must feature prominently in the on-going training of waste handlers. Though ballistic gloves afford protection against sharps injury, the initial segregation and safe disposal of clinical wastes by healthcare professionals must provide the primary control measure. Despite robust and unambiguous legislation and good practice guidelines, serious errors by healthcare staff that result in the disposal of hypodermic needles and other sharps to thin-walled plastic waste sacks places waste handlers at risk of bloodborne virus infection. Further improvement in the standards of waste segregation and disposal by healthcare professionals are still required to protect ancillary and support staff and waste handlers working in the disposal sector.

Clinical wastes in the community: local authority management of clinical wastes from domestic premises.

BACKGROUND: The increasing numbers of patients receiving often complex home-based health care, and the growing number of insulin-dependent diabetic, home haemodialysis and continuous ambulatory peritoneal dialysis patients, contributes to the substantial volumes of clinical waste generated from domestic premises. Arrangements for the collection and safe disposal of these potentially hazardous wastes, generally managed by local authorities, may be inadequate and, in part, unsafe. METHODS: This study audited the websites of the 526 local authorities in England, Wales, Scotland and Northern Ireland. Websites were scrutinized for information concerning clinical waste collections from domestic premises, the limits and constraints on this service, service accessibility, the practical arrangements for collection of wastes, and the health and safety issues of clinical waste management for patients who manage their own care in the community. RESULTS: Two hundred and sixty-two of 526 (50%) local authorities provided information on their websites concerning the collection of clinical wastes from domestic premises. Others referred patients to a district or county council, to another agency or to private contractors (n=72), while the remainder provided an in-house collection service. Weekly collections were most common, although several local authorities offered additional flexibility depending on need. Limits on the minimum or maximum volumes of waste to be collected, or on the types of clinical wastes accepted for disposal, do not support domicillary health care and create an additional burden for patients and their carers. Of particular concern was the health and safety implication of instructions to place potentially hazardous clinical wastes in a freely accessible location outside the home, at the doorstep or on the footpath, as early as 4 am on the day of collection or the night before collection. CONCLUSIONS: The arrangements for local authority clinical waste collections from domestic premises are, in part, inadequate and may be unsafe. The arrangements do not properly support domicillary patients or their carers.

Standards of clinical waste management in hospitals--a second look.

METHODS: The arrangements for bulk clinical waste handling were audited in 16 UK hospitals, one year after an earlier audit that revealed many deficiencies in performance. RESULTS: Storage of clinical waste carts in areas accessible to members of the public and failure to lock individual waste carts was common. Waste segregation was poor. Many clinical waste carts and the areas dedicated to their storage were in a poor state of repair. Many instances of clinical waste storage apparently in breach of UK health and safety legislation, of fire regulations, and of the hazardous waste regulations were observed. CONCLUSIONS: The standard of performance in clinical waste management in UK hospitals remains poor, with evidence of neglect of basic hygiene, housekeeping and safety standards. However, codes of practice exist, and despite implementation of the Hazardous Waste Regulations 2006 that provide further control on all wastes management issues, the reality of clinical waste management in some National Health Service (NHS) hospitals continues to be largely inadequate.

Potential compromise of hospital hygiene by clinical waste carts.

Bulk waste storage carts are common in hospitals and undoubtedly assist in the day-to-day management of clinical wastes. They are used for the transport and interim storage of primary clinical waste containers and are often located close to or within hospital buildings to receive such wastes from clinical departments. Examination of a random selection of bulk clinical waste carts at nine acute hospitals across Greater London revealed external soiling in all of 23 carts. Eight of 13 carts were also soiled on the inner surfaces, with evidence of bloodstains and free fluids in the base of five carts. Staphylococcus aureus and enterococci were recovered in low numbers from the lids (N=7) and wheels (N=10) of carts and Escherichia coli, Enterobacter spp. and Pseudomonas aeruginosa were recovered from the wheels of a further five carts. Two carts were heavily contaminated with Aspergillus spp. Pathogens originating from clinical wastes may be transferred from contaminated bulk waste carts to the wider hospital environment. It may be advisable to keep bulk carts outside clinical areas, and preferably outside all hospital buildings. This becomes particularly important in circumstances where carts supplied by contractors are not dedicated to a single hospital or National Health Service trust.

Lowering standards of clinical waste management: do the hazardous waste regulations conflict with the CDC's universal/standard precautions?

Clinical waste is a costly and troublesome commodity. Comprising the detritus of medical care, the foremost hazard is the risk of infection from micro-organisms present in these wastes. Infection commonly occurs through penetrating injury, the so-called 'sharps' or 'needlestick' injury, although contamination of non-intact skin or splashes to the eye may transmit infection. Bloodborne viruses (hepatitis B, hepatitis C, human immunodeficiency virus) are the most serious threat, although respiratory, soft tissue and enteric infections are not unknown. The European Hazardous Waste Directive, that harmonizes the categorization and control of wastes, permits downregulation of clinical wastes where the risk of infection may be low. Although strengthened by the requirement for risk assessment in waste classification, UK regulatory guidance promoting classification of some clinical wastes as non-hazardous completely ignores the Centers for Disease Control and Prevention's Universal Precautions for the prevention of transmission of human immunodeficiency virus, hepatitis B virus and other bloodborne pathogens in healthcare settings, which seek to prevent bloodborne virus infection in healthcare workers and others, and the more extensive Standard Precautions that extend these principles to the prevention of healthcare-associated infections and the environmental spread of nosocomial pathogens. By creating a potent cost driver encouraging downregulation of some clinical wastes, UK legislation based on the European Hazardous Waste Directive conflicts with the CDC's Universal/Standard Precautions.

Standards of clinical waste management in UK hospitals.

The arrangements for bulk clinical waste handling were observed in 26 UK hospitals. Storage of waste carts in areas freely accessible to the public, and failure to lock individual carts was common. Many clinical waste carts and areas dedicated to their storage were in a poor state of repair. Substantial improvement is required in the management of clinical waste in hospitals in order: (1) to eliminate the possibility of acquired infection through unauthorized, inappropriate access to clinical waste and to minimize adverse effects resulting from contact with waste pharmaceuticals; (2) to comply with the Duty of Care imposed by UK Health & Safety legislation; and (3) to satisfy concerns regarding the general standard of hospital hygiene.

Medical wastes management in the south of Brazil.

Medical (clinical) wastes are costly in disposal and carry risks of infection, or physical injury, and of exposure to potentially harmful pharmaceuticals, as well as being aesthetically unacceptable. Technological advances in disposal, together with the introduction of rigorous emission standards for incinerators and similarly stringent control standards for non-burn "alternate" disposal technologies, continue to drive improvements in waste management. Are these improvements attainable in developing countries? Where adequate resources and a robust infrastructure are lacking, investment in advanced disposal technologies may be counterproductive. Developments must be appropriate to and manageable by the communities served; sustainable low-technology approaches may be preferable. There remains a need for affordable technical innovation, as well as underlying political support and international financial and technical assistance, to sustain meaningful improvements in waste management in remote and isolated regions and more generally in developing countries.

The disposal of clinical wastes.

The disposal of clinical wastes is often poorly conducted and inadequately supervised despite the publication of clear and definitive working guidelines and the introduction of increasingly stringent legislative control. The move away from landfill disposal of clinical wastes, and the further development of high temperature incinerators able to meet increasingly tight emission limits, is to be applauded but has inevitably increased the cost of waste disposal. Moreover, such developments fail to address the continuing 'shop floor' problems whereby wastes enter an inappropriate waste stream or colour coded wastes containers are used for inappropriate purposes thus undermining the value of a nationally approved hazard warning policy. The development of newer waste treatments, including microwave exposure of macerated wastes, may reduce costs and aid in the control of environmental pollution. However, stringent control of this and existing technologies remains essential. Additionally, increasing resources must be directed to improvements in primary waste disposal practices whereby all health care staff have a clear responsibility to ensure correct disposal of wastes without risk to themselves, their colleagues and others, or to the environment.