Injury | Blenkharn Environmental

Glucose testing kit in needlestick incident

There are millions of glucose test lancets used daily, to test the blood sugar levels of individuals with diabetes. I use them daily.

They are used in hospitals – where several incidents have occurred of disease transmission caused by a careless, probably criminally irresponsible, failure to use a new needle or lancet for each patient and to sanitise the lancet holder between patients – and widely used in the community, by every patient with insulin-dependent diabetes and many others with Type II diabetes controlled by drugs and/or diet.

How to dispose of these lancets? In hospitals and other healthcare premises, it should be a straightforward issue of dropping them into a sharps bin immediately after use. At home, matters are less easy. We might hope that insulin-injecting diabetics have been given a sharps bin for their used needles and insulin pens, and the blood test lancets can be placed into these. For others, the change of a GP issuing a sharps bin alongside a blood testing kit are rather slim, if not impossible. And, of course, no straightforward procedure for disposal once a bin has been filled.

Four primary school children in Tasmania have cause a health scare after pricking each other with a needle from a glucose testing kit.

The children at a school in the Derwent Valley, northwest of Hobart, underwent infection tests as a precaution after the needlestick incident on 9 May. “The incident involved four primary school students who used one or more needles from a diabetic test kit to prick each other,” Tasmania’s acting director of public health Dr Mark Veitch said in a statement.

The risk is perhaps small, but not so small as to be discounted and these children will need follow-up over several months. The psychological impact, for the children and more so for their patents, cannot be overstated.

And kids will be kids. Strangely, a discarded needle can be in some way attractive and pierce inquisitive little fingers. That message must reach each and every user of hypodermic needles and blood testing lancets to ensure safe disposal at all times.

Diabetics’ needles

Nobody wants to fund collections of clinical waste from the community. Though some companies make a business out of ‘smalls’ it operates generally on small margins and yet is costly to the PCTs, and now their new era replacements, and to Local Authorities.

Some GP surgeries will receive properly packaged sharps, though often failing to provide on prescription those sharps bins that diabetics will should use. Likewise, some high street pharmacists will accept used needles, as do some hospitals as part of their commitment to outpatient support from diabetic clinics and the like.

It the latter case, patients may take their boxed needles at the next outpatient visit, or drop them off at reception. This creates its own problems since the receptionist will not be able to issue by prescription a new sharps bin, creating problems of continuity. In every case, the diversity of options makes administration and funding something of a nightmare.

The US is far behind, since until recently used sharps have entered the trash in the absence of any better and more organised route for safe disposal. But that is changing. For most, the solution has been to prohibit disposal of sharps in household garbage, and to provide sharps safes in accessible locations, at the Police of fire station, at a local supermarket – in the Mall – or at the local County building.

Their are economies of scale. Most self-injecting patients, whether diabetic or others, and almost all IV drug users are sufficiently ambulant that there is no barrier to a visit to the local sharps disposal point. With a network of conveniently located and accessible disposal points, there are logistics advantages as well as savings in administration for funding arrangements. This might also capture some of those ‘private enterprise’ needles from IV drug users and those injecting bodybuilding steroids and tanning supplements that is now on the increase.

The advantages are many and obvious. Perhaps all that stands in the way of this improvement is predictable administrative inertia and public perception issues that can stimulate objections to needle safes placed in locations across the community.

But it seems a good idea, and far better than the present mish-mash arrangements that are many and varied, and subject to frequent change as if deliberately to confuse the service users.

Sharps injury legislation, Ireland

Needle with drop of blood Ireland has not been backward at making the most of EU laws and subsidies though it has now found itself in deep financial peril as a consequence.

But less advantageous though equally worthy EU legislation, to implement the requirements of Council Directive 2010/32/EU, has been surprisingly slow to implement in Ireland. Trade unions have claimed that the health of Irish healthcare workers has been put at risk by Ireland’s failure to implement an EU directive on the use of medical needles.

The Irish Congress of Trade Unions says member states were due to adopt the directive – the eve of International Nurses Day.

ICTU’s legal affairs officer Esther Lynch said needlestick injuries among healthcare workers were ‘notoriously’ unreported – and that workers were injured anywhere between 1,000 and 6,000 times a year. ICTU has called on jobs minister Richard Bruton to implement Irish laws, giving legal effect to the EU directive, without delay.

“The Health & Safety Committee of Congress is recommending the establishment of Needlestick & Sharps injury prevention committees to oversee the implementation of the Directive,” Lynch said.

“These committees should include representatives from all levels, employers and unions including health and safety representatives, occupational health, risk management, purchasing, housekeeping, infection control, employee education and training.”

With a number of high profile sharps injury claims from Ireland in recent months, this is perhaps rather surprising. Hopefully, the lack of formal legislation will not stop healthcare providers from doing the right thing and purchasing safety sharps without delay.

Non-consensual testing after needlestick injury: A legal and ethical drama

Non-consensual testing after needlestick injury is an increasingly important issue for many healthcare workers, and also for police, prison officers and others who have suffered a sharps injury with a needle from an individual who is known but in circumstances where his/her infection status is unknown.

This creates an immediate and hugely important question – do we treat the sharps injury victim with anti-retrovival drugs, or can this be avoided safe in the knowledge that the source patient is not infected?

This particular legal and ethical drama is played out regularly – though in the waste sector the opportunity to identify the source patient is inevitably lost raising the index of suspicion for all sharps injuries in this group.

A recent training case is described here, by Charles Foster and Jonathan Herring of the University of Oxford Practical Ethics blog.

Like many patients in ICU, X is incapacitous. He also needs a lot of care. Much of that care involves needles. Late at night, tired and harassed, Nurse Y is trying to give X an intravenous injection. As happens very commonly, she sticks herself with the needle.

What comes next?

The case is reviewed from the perspective of barristers acting for X and for Y. Played out as if in The Royal Courts of Justice the judgment is of crucial importance, but perhaps surprisingly it is not given. You decide!

Non-BBV infections after needlestick injury

Needle with drop of blood Sharps or needlestick injury carries with it, in some circumstances, a predictable risk of bloodborne virus infection. The statistics, from which risk can be calculated, are well known and relate to the “average” used hollow bore needle used in clinical practise, and sharps injuries occurring during or soon after use.

There are many additional variables including the time between use of the needle and its involvement in a sharps injury, the amount of blood that it contains, the bore of the needle and depth of injury, the immune status of the victim, post-injury care, the virus concentrations in the blood if any, the time interval between injury and post-exposure prophylaxis if this is indicated, and probably other factors of which we know very little.

But we must not close our minds to the possibility that sharps-related infections are limited to HIV, Hepatitis B and Hepatitis C infections. Other infections can and do occur. In fact, the diversity of infections that have been reported is substantial though the list is bolstered by many individual laboratory acquired infections that arise as, one must hope, a one-off occurrence. Continue reading “Non-BBV infections after needlestick injury” »

Bloodborne virus warning over illegal tattooists

There seem to be plenty of tattooists in the UK but perhaps that really isn’t enough to go around, or they are too expensive.

As a – very poor – alternative, it seems that many illegal tattooists are in operation, unregistered and thus unsupervised. The great risk is of bloodborne virus (BBV) infection, and pyogenic infection of those brave enough to have a tattoo.

http://www.bbc.co.uk/news/uk-22320300

But it is the bloodborne virus risk that is our primary concern, since that extends beyond the process of tattooing and may continue as sharps wastes are disposed. The unregistered and unlicensed operation implies a failure to adhere to required standards of hygiene, and therefore to standards of waste management also. Is it likely that an unlicensed tattoo outfit would bother with safe sharps disposal into a suitable sharps bin? Continue reading “Bloodborne virus warning over illegal tattooists” »

This septic isle?

Once again, this week (22nd to 28th April 2013) is the highlight of the Marine Conservation Society’s fight against marine litter with the Big Beach Clean-up.

Over 110 beaches across the UK and Ireland are going to see volunteers coming together to do a beach clean and litter survey which will highlight the issues of beach litter around our coastlines.

http://www.mcsuk.org/foreverfish/index.php

Hosted by your local M&S store team – and all credit to Marks and Sparks for their sponsorship of this valuable quarterly event [let's hope they bring some of their lovely sandwiches] - the beach clean and survey will last a couple of hours, leaving the rest of the day free for you to enjoy the beach. Continue reading “This septic isle?” »

Reversal of no liability finding for needlestick injury

In a landmark case involving reversal of a no liability finding for needlestick injury that occurred in a Queensland holiday apartment the circumstances of injury, and the legal wrangles, send shivers down the spine.

Wright v KB Nut Holdings Pty Ltd [2013] QCA 66

The Queensland Court of Appeal has held a hotel manager liable for a needlestick injury that a guest sustained while staying in a short-term rental apartment, reversing the original decision of no liability.

The trial judge had not been satisfied that a more competent cleaner or system of cleaning would have led to the discovery of the needle (which was in the crease of a stairwell and was dislodged by the guest when she was cleaning the apartment). He did not consider it reasonable to expect an apartment manager or cleaner to search and discover a concealed needle.

The Court of Appeal reversed this decision, finding that:

it is likely a cleaner using normal skill, diligence and equipment would have detected the needle;
it was probable that the needle was obscured from the guest’s vision as a direct result of the unclean state in which the apartment was handed over to her;
the hotel manager knew or should have known of the risk of injury; and
the build-up of ‘filth’ in the apartment increased the risk that dangerous objects would not be seen until after they were stood on or touched, which may have been with bare feet or hands.

The hotel manager was ordered to pay compensation of $494,759.38, plus interest.

This decision confirms the importance that rental property owners need to place on implementing thorough systems of regular cleaning and inspections.

Quite right too. But isn’t it a warning also, that if you arrive at a rental apartment or hotel room, the immediate response when finding it dirty is to walk back out again and go somewhere else – its not your job to get down and clean it!

And of course, we wish the injured guest well, with the medical and psychological implications of that sharps injury. AS$494,759.38 (about £330.000) should help.

Psychiatric consequences of needlestick injury

Some time has passed since this paper by Green and Griffiths was published. Unsurprisingly, the professional journals and magazines, and the trades union RCN are up in arms about the impact to nurses, and separately to surgeons and physicians. Quite right too.

But the paper, which investigated the psychological welfare of 17 individuals having sharps injury. Only 5 of these five (29%) were in “the health sector (nurses and paramedics)” while the remainder fell into a category of ‘other occupations’ which involved police officers, porters, cleaners, a builder, a manager and one unemployed person.

Of the 3 brief case individual reports included in the paper, only 1 was a healthcare worker. This lady was injured while working in an accident and emergency department. Perhaps a nurse, or possibly a support worker/cleaner, we are not told, the lady was emptying a clinic bin and was replacing a bag when a needle, which had been incorrectly disposed of, pierced her leg. The remaining 2 cases involved a coach driver and postal worker respectively.

Leaving aside the serious issue of a healthcare professional incorrectly placing a used needle into a soft-walled clinical waste sack, the occupations of those involved in this sharps injury series requires further consideration. With so much noised from the medical and nursing professions, about the risks and impact of sharps injury that they may face, it seems that it is the ancillary worker and others who are at real risk.

We at Blenkharn Environmental and at the Clinical Waste Discussion Forum and are doing all we can to highlight the risks of waste handlers and ancillary and support staff. Perhaps the waste and services sectors simply have no voice. At least, they could shout a little louder.

Pupils play with clinical wastes at Indian dump

Pupils of the Mandal Praja Parishad primary school at Achayyapeta have found some new “toys” to play with. During the recess and after school , the boys and girls run to the garbage dumps less than 350 meters away and search and pick up used injection syringes and IV fluid sets and start playing by filling them up with water.

Their parents, mostly away from the village rearing sheep or working on fields, are genuinely worried about the children contracting diseases. For the villagers, who are fighting all out to stop the Anakapalle Municipality from dumping the town’s garbage in their village, the threat to their children’s health appears to be the immediate major problem even as they wait for the High Court to give them a favourable verdict. The medical waste is part of garbage forcibly dumped on a site allotted to the municipality as a dumping yard on March 20 after chasing away the protesting villagers and arresting 20 of them.

more at http://www.thehindu.com/news/cities/Visakhapatnam/students-play-with-medical-waste-at-achayyapeta/article4609569.ece

Sharps injury – how much compensation?

Needle with drop of blood I am often asked how much compensation might be expected after a sharps injury, and this is one of the common search terms used when visiting the Clinical Waste Discussion Forum.

For most ancillary workers and waste handlers, expect around £3k, though with legal fees the defendant might expect the cost to fall between £7-10k.

In one notable case here in London, a young doctor suffered a sharps injury and claimed post-traumatic anxiety and stress symptoms that made it impossible for her to handle a needle again. This blighted her career and in the High Court she picked up £500,000! But not so for the rank and file who fare much less well.

Now a recent South Australia case a mum of four has been awarded $494,750 compensation after a holiday unit needlestick incident. The Claimant lived for 18 months with the fear of getting HIV after being stuck by a needle in a “filthy” Brisbane holiday apartment and says she has never recovered from the anxiety of having repeated “indeterminate” HIV test results, until finally getting the all-clear. “It’s ruined my life”.

We should be pleased for the Claimant, that she has finally been shown not to be infected with HIV. The sum awarded, plus no doubt not inconsiderable costs will be picked up by the insurance company. That sum total is the true cost of a sharps injury, which pays more for the post-injury psychological damage than physical injury. Quite rightly, this shows some recognition of the sometimes profound stress and anxiety that can follow sharps injury. In the UK and UK, solicitors are becoming well aware of this and plan their case accordingly, so expect the defence to demand ever more stringent tests to conform the validity of psychological trauma.

Regrettably, there still seems a considerable divide in the sum awarded with compensation payments ranging from £3k to £500k. But then, life is not fair.

‘Sharps’ injury is as traumatic as car crash

The psychiatric distress caused by having a ‘sharps’ injury is consistent with being in a car crash, a study has revealed.

Published in the journal Occupational Medicine, the study explored the psychological effects of needlestick injuries, which can affect an estimated 100,000 people per year.

The study compared levels of depression and symptoms of post-traumatic stress disorder in people who had a ‘sharps’ injury with a control group who had suffered a different psychiatric trauma.

The researchers found that although none of the participants contracted an infection from their injury, psychiatric illness and distress lasted close to two months longer for every month the patient waited for test results.

“The chances of physical damage are what are focused on by society, but these risks are in reality very small,” said lead researcher Professor Ben Green.

He said: “The main health implication of needlestick incidents is probably psychiatric injury caused by fear and worry.” Continue reading “‘Sharps’ injury is as traumatic as car crash” »

Needlestick – does the law help protect?

In a House of Lords debate on 14 March 2013, Lord Turnburg asked the Government “what is their policy on testing for HIV in patients lacking capacity to give consent following a needlestick injury to a healthcare worker”.

It’s an important question, since source testing can shape the early decisions to administer potent but toxic and unpleasant anti-HIV drugs to the injured person.

The reply, from Earl Howe (Parliamentary Under Secretary of State (Quality), Health; Conservative) was that “Where a person lacks capacity to consent their rights are protected by the Mental Capacity Act 2005, which determines that decisions on behalf of such a person have to be made in their best interests.

The department’s view is that both the taking of samples and the testing of samples previously obtained from a patient who lacks capacity to consent are therefore acts that may only be undertaken if they are in the best interests of the patient. This would include testing a patient for a serious communicable disease such as HIV following a needlestick injury to a healthcare worker.

The department’s view is that determining whether it is in the best interests of a patient who lacks capacity to take and test samples for the purpose of determining what treatment, if any, to offer a healthcare worker with a needlestick injury is a stringent test to pass. It involves assessment of the individual circumstances of the patient on a case-by-case basis.”

That’s a tough call, and one that might be better answered by the Government rather than the patient’s carers. A policy would help, rather than a fudge answer that expects the healthcare team to interpret complex legal matters – in haste – in the knowledge that it may come back and bite them in later High Court action. For the needlestick ‘victim’ that offers no solace.

Neither too does it offer anything to the injured waste handler working as a hospital ancillary and support worker, in the waste management sector or for a Local Authority. For them, a needlestick injury will always be the same result – do we assume the worst and embark on a long and difficult course of ant-HIV medications since the source patient on whom the needle was used, or the user who discarded the needle, will always be unknown.

The Government might have helped with a straightforward yes or no, but regrettably the law is almost never that simple. But for those in eh waste management sectors, the opportunity will not arise anyway. The source is unknown.

On every post-exposure treatment algorithm, this places the injured person in the highest risk category. Other factors are involved such as the likely age of the needle, was it a deep wound from a large hollow bore needle – but did you stop to find out? – but this involves always something of a terrible gamble.

A gamble with a life. Make sure that its not yours or one of your workforce.

Anxious wait for 12 year old girl who fell onto a discarded needle

A 12 year old Sunbury, Australia, girl faces an anxious wait after falling onto a discarded needle.

The girl slipped and fell playing in a park near Gibbons St Sunbury, cutting her arm on the hidden needle. She did not tell parents until later, when the arm became sore and swollen and they got medical help.

“I remember running towards the slide when I slipped and fell, landing on my left arm,” she said.

“I felt a sharp pain … and saw the needle, which I picked up and put in the bin.

“I wasn’t very happy about it at the time but I was too scared to tell my parents in case they blamed me.”

Her angry father has hit out at whoever discarded the needle, labelling it “irresponsible and dangerous”.

http://www.heraldsun.com.au/leader/north/agonising-wait-for-12-year-old-sunbury-girl-after-she-fell-on-a-discarded-needle/story-fnglenug-1226605528310

Understandably, this is the cause for great distress, for the child and her parents and family. Not just today, but for the many months of follow-up that will follow, and possibly beyond. The impact is profound, and we wish them well.

Regrettably, stories like this are not uncommon. They serve to highlight the considerable risks from discarded needles, that seem far more common in recreational areas than elsewhere.

Postal restrictions on the carriage of biohazardous materials and sharps

UK postal restrictions forbid the packaging and shipment of small quantities of sharps to some distant disposal centre, even when packages in a sealed ISO-compliant sharps container and suitably impervious outer wrapper.

That creates a problem for many community-based sharps users who must package their used insulin syringes and take these to a co-operating high street pharmacy, to a GP surgery of to the local hospital. Since funding for this additional waste stream is often overlooked and does not flow equitably from the PCT patients are often left to struggle to find someone who will take their sharps waste.

Let’s not fool ourselves into believing that in the US they have it right, since in may States the management of sharps from domestic users is simply appalling. However, some States and cities do operate or permit a sharps by post service. These seem to operate well, with no reported incidents. They must save money, and make life easier for all.

So, why not in the UK? The official answer if to blame Europe, which forbids shipment of bio-hazardous materials by post.

But in the UK, the NHS Bowel Cancer Screening Programme, operates nationally to invite all over-60s to send 3 tiny samples of faeces to a central testing lab. All for the very best of reasons, and repeated through advancing age, the programme seeks to identify those who warrant further and more detailed investigation for the detection of early, and very much treatable, bowel cancer.

How does it work? Just 3 smears of faeces on a set of test cards folded into a paper envelope. With name and dates etc clearly marked, these are placed into a simply unpadded plastic pre-paid envelope and sent 1st class letter post to the lab.

If this is permissible under UK (or European) postal regulations then why not the shipment of suitable sealed and packaged small sharps bins for personal use?

Is there a hygiene risk? A risk of spillage, perhaps of faeces, or of sharps penetration though an ISO-compliant bin? Is the welfare or health & safety of postal workers in jeopardy? Is there some de minimis scale of bio-hazardous materials, and do thousands of faecal smears fall below the line?

It seems, regrettably, that we have looked at Post Office regulations and talked our way out of a perfectly good method for disposal of small numbers of used sharps that might arise from trustworthy and competent patients who might otherwise struggle to dispose of their used sharps.

What a great shame that is.

Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for employers and employees

Needle with drop of blood The Health and Safety Executive have published “Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 Guidance for employers and employees “This information sheet is for healthcare employers and employees. It will help you understand your legal obligations under the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 (the Sharps Regulations). The Regulations implement aspects of the European Council Directive 2010/32/EU (the Sharps Directive) that are not specifically addressed in existing GB legislation. They will apply from 11 May 2013.

All employers are required under existing health and safety law to ensure that risks from sharps injuries are adequately assessed and appropriate control measures are in place. The Sharps Regulations build on the existing law and provide specific detail on requirements that must be taken by healthcare employers and their contractors. This information sheet should be read in conjunction with other information on managing the risks of sharps injuries, and the associated risks of infection from blood-borne viruses. HSE guidance and links to other relevant guidance can be found on HSE’s website.”

It explains under what circumstances the Regulations apply, and provides practical advice on:

the safe use and disposal of sharps
training requirements
procedures for responding to a sharps injury

http://www.hse.gov.uk/pubns/hsis7.htm

No to compensation for childrens’ sharps injuries

“Two children, aged three and four when they suffered “needlestick” injuries while playing in a rubbish-strewn park, have each lost €38,000 damages claims against a local authority.

“Judge Matthew Deery said the grave upset of their parents, who understood the dangers associated with such wounds, had not been mirrored in the children.

“The judge said Lee Cox (4) and Helen Brown (3) had been taken to their doctors to get injections, which was not uncommon for children. Fears that might attach to an adult of developing blood-borne diseases could not be associated with them.

“Judge Deery, dismissing the claims, added that the council had installed CCTV and employed specialist teams of staff with a tractor and trailer and a JCB to keep rubbish cleared from the park. The court could not say the local authority had acted with reckless disregard of the children.

http://www.independent.ie/irish-news/courts/children-lose-claim-for-38000-for-syringe-injuries-suffered-from-playing-in-local-park-29101270.html#sthash.cxRzZUTh.dpuf

I feel terribly sad about this. Though it is suggested that the Local Authority had made reasonable attempts at managing the situation of needle discards in this area, it nonetheless remains that the children did suffer a sharps injury and as a consequence had to undergo investigation and preventive treatments over a long follow-up period.

Too young perhaps to suffer significant psychological trauma, though now living with a fear of needles, it seems that it was Mum who suffered more. This was not reflected in the judgement, and perhaps in the eyes of the law it should not have been since the report refers only to a claim on behalf of injuries etc suffered by the two children but not their mother.

That is a tough decision, and perhaps one on which the instructing solicitor should reflect. Was the claim properly constructed?

The report makes sobering reading, not for the loss of a compensation claim, but to raise awareness that a sharps injury can impart a significant psychological distress in the affected individuals, and in the larger family group, whether the partner or parents of an affected individual. That needs to be recognised, and recognised in law.

Ian

The Safer Sharps EU Directive – NHS Supply Chain regional events

Needle with drop of blood NHS Supply Chain is running 8 regional events across the UK, 7 events for NHS staff and one event non-NHS staff. These days are being split into two, with the mornings covering the Safer Sharps EU Directive and the afternoons covering NPSA Safer Spinal Epidural Part B alert.

Location	Date	Venue	Events available
Bristol	Tuesday 5 March 2013	Hilton Bristol Hotel	Both Safer Sharps and Spinal
Birmingham	Wednesday 6 March 2013	Hilton Birmingham Metropole	Safer Spinal Only (Afternoon session)
Manchester	Friday 8 March	Hilton Manchester Deansgate	Both Safer Sharps and Spinal
Brighton	Monday 11 March 2013	Hilton Brighton Metropole	Both Safer Sharps and Spinal
London	Friday 15 March 2013	Hilton London Towerbridge	Both Safer Sharps and Spinal
Leeds	Friday 22 March 2013	Doubletree by Hilton Leeds	Both Safer Sharps and Spinal
Newcastle	Tuesday 26 March 2013	Doubletree by Hilton Newcastle	Both Safer Sharps and Spinal

Registration for these events will close 7 days prior to the event taking place

Event information

Full agenda and venue information will be sent along with confirmation of place up to one week before the event. Please note: Event timings are subject to change slightly, dependent upon the availability of guest speakers

Safer Sharps event schedule		Safer Spinal event schedule
09:30am	Presentations	1:30pm	Presentations
10:30am	Questions and answers	2:00pm	Questions and answers
11:00am	Supplier product demonstrations	2:30pm	Supplier product demonstrations
12.30pm	Close	4:00pm	Close

These events offer:

Support and guidance from our Clinical Nurse Advisors, Procurement team and Account Managers
An overview of the range of new devices available from a wide range of suppliers
Support for NHS organisations with purchasing for safety initiative
Access to representatives from manufacturers to give advice, support and training
Access to representatives from relevant associations
An opportunity to arrange future local trials and evaluations.

Supported by:

Royal College of Nursing
Health and Safety Executive
Health Protection Agency
Safer Needles Network
NHS Commissioning Board

http://www.supplychain.nhs.uk/events/invites/clinical-event-days/

It would be wonderful if these sessions included authoritative information concerning safe disposal, and of the other features of Council Directive 2010/32/EU that mandates an improved sharps injury management protocol and effective review and follow-up by suitably qualified specialists. However, that is not to be.

The long-term psychological impact of sharps injury

Even a relatively minor – none can be described as trivial – sharps injury or blood or bloodstained body fluid exposure can result in short-term or longer-lasting psychological harm. This may manifest as post-traumatic stress and anxiety, sometimes affecting an entire family group, forcing a change of career or occasionally an inability to work at all. The loss of income exacerbates the stress impact, resulting in sometimes life-long change to lives.

We have discussed this many times previously on the Clinical Waste Discussion Forum, too often to list here. Users wishing to review these posts can use the site search function or browse the archive files, which are not included in the search system.

Now, in a short report by Zhang and Yu from The Second Affiliated Hospital of Soochow University, Suzhou, China (Zhang MX, Yu Y. A study of the psychological impact of sharps injuries on health care workers in China. Am J Infect Contr 2013; 41(2): 186-7) the level of concern of sharps injury for healthcare workers are noted to be related to a number of adverse effects, including both physical problems and economic burdens, as well as psychological impacts. The authors note that published research in this area is limited compared with reports describing the incidence of sharps injury, situations when it happens, risk factors, and economic costs.

361 subjects (180 males and 181 females; 186 nurses and 175 doctors) were recruited to the study, all of whom had experienced at least one sharps injury. The majority (64.3%) did not report their injury.

The data show that 15.2% of respondents reported manifestations of emotional distress, such as anxiety, worry, frustration, panic, and even extremity numbness, after experiencing a sharps injury. More than half (57.6%) reported feeling that they had been or would become infected from their injury.

93.9% of respondents indicated that the major factor inducing negative psychological changes was the fear of infection of themselves or family members.

Another factor that caused frustration in HCWs was the inability to completely protect their own rights and benefits. Over-excessive behavior can be induced by psychological stress; 39.6% of respondents reported engaging in over-excessive behavior, with a significantly higher incidence in women than in men (P <0.05).

67.9% reported that their careers had been affected by their sharps injury, including diminished professional recognition and reduced professional enthusiasm. These effects were greater in the younger respondents (aged 20-30 years; P <0.05).

The comparable results for ancillary workers and waste handlers are unknown since, as yet, no large study has been contemplated. In all probability, the results may differ from those noted for healthcare workers since education and understanding of the issues involved are likely to be markedly different, sharping responses to sharps injury, even with full engagement with an appropriate medical follow-up.

The outcomes of sharps injury in waste handlers has been poor, with many not reporting injuries as these are seen as something of an inevitability, becoming almost routine; splash exposure with blood or bloodstained body fluids are generally, and incorrectly, not recognised as risk events. First aid and follow-up support is often limited, even in larger companies with an effective and accessible occupational health service that is likely to be detached from the ‘shop floor’ and effectively inaccessible in any reasonable timescale.

A local Accident and Emergency Department is the best port of call, though where there is a choice travel to a larger city hospital is likely to be a wise choice since these may have the appropriate specialist services.

Demand attention. Don’t be fobbed off as a trivial injury that can be managed at home with just a band aid. A comprehensive clinical review, preferably with urgent referral to a specialist infectious disease service. Despite this, it is still inevitable that some will be turned away from A&E, or left to wait for many hours in circumstances where early administration of post-exposure prophylaxis antiviral drugs, if indicated, is time critical.

Council Directive 2010/32/EU won’t help. Though this requires that each healthcare service develops strategies to minimise sharps injury and introduces safety sharps these are likely to be discarded without activation, into flimsy waste sacks rather than sharps bins, in the same way as at present. A safety sharps device will not change that negative attitude to safety and the welfare of others. Elsewhere, Trusts are required to develop plans for effective and rapid management of sharps injury with referral of staff to specialist services. Though it is intended that this care will be extended to contract staff such as cleaners and porters working permanently on-site, those not working for a healthcare provided are not included in this legislation and are likely to be denied access.

“Blood-covered needle” in Tesco loaf

A mother opened a loaf of bread bought at a Tesco store to make a sandwich for her 10-year-old – only to discover it contained a blood-covered needle used by a heroin-taking grandfather.

The mother had taken two slices from the pack of Roberts wholemeal bread – which she had bought from the Tesco Express in Pendlebury, Greater Manchester – when she made the shocking discovery.

The needle had been pushed through the plastic wrapper by David Rodgers, 61, when he visited the shop with his wife, in a desperate attempt to avoid her finding out he was back on the drug.

Rodgers had already used the needle for a heroin fix before he hid it in the bread last December.

The mother, who bought the loaf later that day, was left ‘alarmed and distressed’ when she noticed the syringe while making the sandwich for her son, Manchester Magistrates’ Court heard.

Regrettably, Tesco may get more bad press from this, but quite undeservedly so. However, it does serve to highlight the ever present risk of sharps exposure often in the most unlikely of locations.

Needle exchange in prison

In Australia, the prison system has introduced needle exchange schemes to eliminate, as far as possible, the hazards to health of needle sharing among the prison population.

Rates of Hepatitis B and C and HIV are high and with a high incidence of IV drug abuse needle sharing had become inevitable, with a corresponding decline in standards of prison health.

Questions in today’s BMJ refer to the “glacially slow worldwide movement of redressing health inequalities in prisoners”, and the lack of such needle exchange schemes in UK prisons is singled out for criticism.

“Why is it taking so long for this policy to be rolled out in the UK? Regardless of personal views on whether prison should be for punishment or rehabilitation, it should not be punitive to health.

“Despite the UK Department of Health’s intention back in 1999 to “identify health problems, deliver treatment and ensure seamless transition back into the community,” the government seems unable to turn this into policy. Community needle exchange programmes have a long history of reducing harms, particularly the transmission of blood borne viruses such as HIV and hepatitis C. They also encourage people to engage with drug health services, thereby enabling social and psychological problems to be tackled.

“The rationale for needle exchange programmes in prisons is also clear. According to the 2010 Patel report, around 69% of people entering prisons had taken drugs within the past 12 months—40% of them within the past 28 days. Another UK report found that 69-75% of prisoners who had injected drugs inside prisons shared needles. A review of prison needle exchange programmes published in 2003 showed that they are feasible, reduce risky behaviour and the transmission of blood borne infection, and have no unintended negative consequences. Fears that needles could be used as weapons in prisons seem to be unfounded. The benefits of prison needle exchange programmes were also documented in a best practice guide published by the National AIDS Trust in 2011.

Brett J. Why have prison needle exchange programmes not yet been rolled out in the UK? BMJ 2012;345:e6211

There are several issues of concern. Is the management of sharps waste in prisons adequate? What is, and can more be done to reduce, the risk of sharps injury among prison staff and others?

Greater control of drug abuse and the health risks associated by needle sharing in prisons may well be achieved by the introduction of needle exchange schemes. Alternatively, might there be a case for some reasonable security in prisons, to keep prisoners in and drugs and needles out? That too will have a significant positive impact on health, reducing the risks of needle sharing and sharps injury.

NHS failures in safe transport of sharps – Community care services

The Department of Health has issued an Estates and Facilities Alert (ref EFA/2013/001) concerning ‘Sharps and sharps containers transported in staff vehicles‘.

It follows exposed or inadequately protected sharps left in healthcare staff vehicles which put occupants and service personnel at risk of needlestick injury. In particular, The Health and Safety Executive is concerned about needlestick injuries reported by a car leasing company which employs servicing and valeting personnel. The injuries were caused by used, loose and unprotected hypodermic needles (sharps) left in lease or ex-lease vehicles used by clinical staff.

Clearly, someone fouled up, big time. Perhaps more than one person, and more than one time, though detail of the incidents is not given. The Alert makes it clear that individuals at the fleet hire company(ies) have been injured and unused sharps don’t fall out of their wrappers unaided, so we can assume a problem with used sharps also. The scant detail in the Alert suggests at best a lack of care and an unprofessional approach to safety that should, perhaps, be the subject for disciplinary action.

Is this likely to be in cars used by community nursing staff, who represent the biggest fleet user group in the NHS? We have discussed this previously on the Clinical Waste Discussion Forum. That possibility seems entirely plausible, but sits uncomfortably against the fuss generated by those same nurses who for a time poured vitriol on just about everyone while refusing to carry clinical wastes in “their” cars on their return from patient visits.

Safety engineered needles – do the help?

Safety engineered needles – do the help? It’s a straightforward question and the answer will, for most people, be an unequivocal yes. Of course, we *hope* that the answer is yes but the evidence points only to a reduction in sharps injury immediately following syringe use and during disposal.

Before and during use, when the needle will be exposed, accident rates are unlikely ever to be reduced except with the very best of care and good technique. Later on, after disposal, should we expect any reduction in injury rates? I say no, and have said so for several years now. There is much to read on the subject in the archives of the Clinical Waste Discussion Forum.

It’s a simple concept – the used sharps that cause injury are not those which have been placed safety into a quality sharps bins but those protruding from the overfilled top, others placed carelessly into waste sacks or lost within soiled linen, and those tossed aside without a care for the health and welfare of others by the growing numbers of IV drug abusers.

So the answer to the question “Safety engineered needles – do the help?” is not quite so straightforward.

Now, others have added their voice to this. In a recent online conference 78% of healthcare professionals indicated their believe that needlestick injuries have not been eliminated since the introduction of safety engineered sharps reinforcing the fact that there is much to be done in needlestick and sharps related prevention.

The findings came out of the online conference hosted by Safe in Common, a non-profit organization of healthcare safety advocates dedicated to eradicating needlestick and sharps-related injuries, held in November. Nearly 1,000 healthcare personnel registered to take part in the first-ever multimedia exploration of the past, present and future of needlestick safety. The event was created to renew a dialogue among key opinion leaders, experts, and the healthcare personnel whose work environments are fraught with needlestick and sharps injuries despite legislation mandating the use of safety devices for their protection.

Clearly, there is much still to do. And from our own perspective, work to reduce or eliminate sharps injuries to ancillary staff and waste handlers is only in it’s infancy. We must work hard to ensure it survives infancy and flourishes to protect against these feared injuries.

Sharps safety gloves – a new and improved test method?

Sharps safety gloves, and the ballistic panels in trousers, are crucially important in so many ways. Used by the Police, prison and security services and, of course, by all of those working with healthcare wastes, they are often the only hope of protection against sharps injury.

Several different types of glove are available, with just 2 or 3 main supplies each having their own glove type. These differ by the conformation of stitching, flexibility & tactility, and by the ease of fit together with the extent to which the cuff extends to cover and protect the wrist and lower par of the forearm.

The gloves are expensive and in use may not last too long before replacement is necessary. They often allow penetration of fluids along stitch lines, while others are so impervious that the hands suffer with excess sweat. And those stitch lines can be particularly troublesome since the stiff raised fold of material and heavy stitching between the fingers can cause rubbing and chaffing that breaks skin surfaces ad risks infection when those areas later become contaminated with materials for the waste being handled.

So, how do we choose the best glove? The one giving the very best protection at the keenest price, providing tactility and comfort with enhanced protection? The ones that will prevent injury and eliminate the risk of infection? The one that enhances the health & safety of the waste handler

It is claimed that current standardized test methods do not correctly evaluate the resistance of protective gloves to these punctures and do not take into account the effect of the presence of a hand inside the glove. IRSST, a safety research organization located in Montreal, Canada, has published a new study in response to joint requests to identify gloves that afford adequate needlestick protection, to develop a method for characterizing the actual resistance of gloves to puncture by very pointed objects such as needles, with this method later becoming the subject of a standard.

The study will determine the degree of dexterity and sensitivity that these gloves offer to workers. The data collected in the IRSST study will help users choose the puncture-resistant gloves most appropriate for their task, thus promoting their wear and helping to reduce the number of injuries to workers’ hands. These results will be exportable to other activity sectors, including the hospital environment, and will be useful to manufacturers for improving their products.

The study results (http://www.irsst.qc.ca/media/documents/PubIRSST/R-753.pdf) make interesting reading. We should look forward to open and constructive discussion between manufacturers and users, to formulate from these data a new ISO or equivalent standard. Regrettably, there is likely to be some attempts at stalling of this process, if company X believes that the test protocol is favorable to the competitor Y but not to their own product. We can understand this stance, but in the absence of a better proposal it should be hoped that a standard will be defined, to provide the best glove offering comfort and enhanced performance with protection of sharps injury.

Agreeing standards proposals can be a hugely troublesome process. Large companies can flood the process with their suppliers and contractors to enhance their vote, while others seek to over-represent the views of their sponsor sometimes without the integrity to admit the conflict of interest that supports their particular role. Still other abuses exist, at at BSi, where those on the assessment committees have failed to manage properly an open and all-embracing consultation process on the basis that asking the various stakeholder groups ‘can secure views and comments that are not particularly helpful’!

Clearly, all is not well in the world of the international standards organisations. However, let’s hope that this latest report that proposes enhanced test methods for sharps protection gloves does not get buried beneath the fog of vested interests and abuse of process.

2010/32/EU – don’t use safety sharps?

In a surprisingly practical note to the The European Journal of Hospital Pharmacy: Science and Practice (EJHP) a UK pharmacist discusses the many situations occurring outside the immediate clinical environment where the use of engineered safety devices may be inconvenient and, in some cases, positively disadvantageous.

Others similar scenarios arise, with needles and blades used for a diversity of higher-risk patient focused interventions. The rationale is that it may just not be possible to obtain a safety engineered device for a particular purpose, or that may be significantly more difficult to use and patient care standards may decline. After all, it should be risk assessed.

But somehow or other, sharps must enter the clinical waste stream. In a suitably designed sharps bin that is acceptable though some bins are far better than others. Regrettably, not all sharps are disposed that way and a constant stream of used sharps find their way into clinical waste sacks intended only for soft wastes. Inevitably therefore, the interpretation of any risk assessment should assess also that possibility, as well as the impact of use. And let’s not pretend that ‘professionals’ don’t get it wrong. That is patently incorrect.

In addition to used needles and blades, other sharp wastes find their way into teh clinical waste sack. Sharp plastics can cut or tear their way through a sack and cut or puncture the skin surface. Some will say that its a piece of so and so packaging, perhaps even something that shouldn’t have been there in the first place! Well, that’s as maybe, but once it has cut a finger or punctured a leg, there can be little solace in such words.

Others will say, and regrettably I have heard this also, that the item would not have been contaminated so will be OK, discounting and possibility for cross-contamination with fresh blood in the milieu of the clinical waste sack.

I have no doubt that there are many cases for NOT using engineered safety devices, in circumstances where the various risks might properly outweigh the advantages. However, overall, those should be few in number. Shrouded in mis-understanding and mis-interpretation, this can lead to an incorrectly dismissive attitude toward sharps injury. It can be difficult for waste handlers to obtain adequate care for sharps injury in A&E as workers are still being fobbed off with an admonition for wasting NHS time for a trivial invisible injury without a moments thought for the implications.

Beware sharps injury. Take it very seriously if you are affected - adding blood splash to the mouth or eyes, or to raw broken skin caused by an earlier cut or graze, dermatitis or eczema, together with an obvious sharps injury. Go straight to the nearest A&E department, selecting a larger university hospital if this is available nearby as the service will more likely have access to specialist infectious diseases physicians. And lastly, make a fuss. Don’t be fobbed off or referred to your GP, don’t be dismissed from the department or pushed down to the bottom of the waiting list as time is critical. The probability is hugely in favour of no infection, but that’s not a gamble that you should take.

Joining the needlestick prevention bandwagon?

A great many companies and organisations are presently joining the needlestick prevention bandwagon. Most are echoing information that has been presented previously, often as their own, and fail to take matters any further forward.

But now, the best – so far – of the bandwagon seems to be the iSecure syringe. This novel syringe design has many innovative features but above all is claimed to address the risk of needlestick injuries. Until, that is, it is prepared for use….by fitting a needle to the end of it!

Somehow, coals to Newcastle come to mind.

Sharps safety regulation

The consultation on the HSE review of impending sharps safety regulation following EU Council Directive 2010/32/EU is now closed.

Currently, IOSH is trumpeting its own submission that proposes, as Blenkharn Environmental and others have also done, an extension of the formal protection afforded to include protection to those outside the healthcare sector who might be exposed to, or injured by, sharps.

That stance cannot be criticised. However sympathetic this stance may be, the thrust of their argument misses important detail. There is little value in providing safety sharps as far as sharps injury reduction from discarded drug litter is concerned. It will still be discarded, and safety devices, if provided, are unlikely to be activated. The issue of fully automatic devices to diabetics and IV drug uses is unthinkable. Sad as it is, it will simply be too expensive.

The real necessity is to comprehend the need for defined protocols for sharps injury management, for use in every A&E department. This will stop Local Authorities suggesting that residents stuck by a needle should write in for a free leaflet or make an appointment with their GP, and will stop those working in the commercial sector being referred to an off-site occupational health provider that might result in a week-long delay for attention. That is simply not good enough.

It is imperative that those presenting to A&E should not be fobbed off as time wasters with nothing more that a trivial injury. The potential impact far outweighs the mechanical aspect of the injury received.

2010/32/EU goes much further that requiring safety sharps. It requires also urgent access to specialist Infectious Diseases teams for assessment of the need for and management of post-exposure prophylaxis and careful follow-up. That should apply to all and the DoH, supported by HSE, must ensure that is available for all sharps injury “victims”.

To assess the scale of these problems, and ensure effective monitoring by HSE, it would be advantageous that sharps injury was incorporated specifically into RIDDOR. Mandatory reporting would give HSE some data upon which to act, since their current plan is to puss and blow, but with no plan to develop mechanisms for monitoring of compliance with the new sharps regulation. Cost is no barrier, as the new FFI seems to be an effective money spinner than neutralises the excuse of budget constraint on questions about the activities of HSE.

Lastly, science would fail if it did not flag the importance, yet again, of splash inoculation. This can be an important mechanism for the transmission of bloodborne virus infection. Splashes onto damaged skin, a previous cut or damage due to eczema, psoriasis or chronic dermatitis and splashes to teh eyes of mouth can and do transmit infection. It would be advantageous to include these events also into the upcoming legislation since such events are almost always due to some defect in safe working practice. This is the exact scenario in which HSE would be expected to intervene, but by excluding its incorporation to the proposed legislation and insisting on a mandatory notification scheme it is difficult to envisage a way in which HSE might properly manage this new legislation.

How to make a bad situation worse

Basildon Hospital Trust have failed miserably to separate clinical from domestic-type refuse resulting in what is apparently widespread contamination of a Veolia site.

Now, hospital porters who volunteered for the “horrendous” job of rifling through rubbish to look for used syringes and swabs say Trust bosses have let them down by not paying them on time. Around ten porters from the hospital volunteered to do night shifts at the Veolia Environmental Services waste depot on Burnt Mills Industrial estate, Basildon, to scour refuse contaminated by clinical wastes incorrectly disposed of by nurses and doctors.

The hospital has faced a growing problem of clinical waste going into the general waste stream, but so far we have no word of either the Environment Agency or HSE addressing these breaches. Perhaps they are still sitting on their hands?

In September, Veolia banned any waste from the hospital waste going to landfill and the porters were rummaging through contaminated waste at the depot. One of the porters, who refused to be named after they were banned from speaking to the press, said: “We volunteered for this. OK it meant overtime, but we are really helping the hospital out and it is horrendous work.”

“We have all the gloves and special clothing, but I have put my hand in excrement and clots of blood.

“It is just an insult. We were supposed to get £210 for three shifts before tax, but they have only paid us 60 per cent. Some of us were relying on that money and everyone is very annoyed that they volunteered but got this treatment.”

A hospital spokeswoman said: “The trust can confirm that a clerical error has caused a delay to the additional payments that porters are receiving for working at the Veolia waste site.

“The trust appreciates the additional work that the porters are carrying out at the waste processing site and regrets that a clerical error has delayed a proportion of their additional payments.”

There are serious errors in waste management in general and waste stream separation. The inclusion of sharps with soft clinical wastes in this contaminated waste suggests downstream co-mixing of clinical and domestic wastes rather than incorrect source segregation by, as presumed by the porters, doctors and nurses. In fact, it may even have been the porters mixing bags and bins collected from the wards, or it might have occurred even further downstream in which case the error might sit at Veolia’s feet.

Whatever the circumstances, this represents a clear breach in waste management regulations and EA should be imposing restrictions to ensure no repeat. Depending on severity – it is now placing individuals at significant risk of infection and that health & safety breach may be actionable. HSE might now step in, with FFI charges imposed on the Trust. EA should also concern itself with the actual or potential environmental impact of what is now, and might previously have been, inappropriate landfill disposal of clinical wastes.

Altogether, a bad situation that the Trust has now made much worse.

http://tinyurl.com/cjm3tg8

An addict’s needle – just what are the risks?

Actually, this is an almost impossible question since the risk depended on the type of needle – wide hollow-bore needles are far more dangerous – how much blood, , whether it is liquid or dried, and how old. Then there is the injury? Is it a deep wound or just a scratch, which still carries a risk though not as great and by no means is it a trivial or risk-free injury.

Needles discarded by addicts, IV drug users (IDUs) or the new softy softy term people who inject drugs (PWID) to include diabetics and others who are using needles and injectable therapies quite legitimately, are a constant risk for waste handlers and others. Picking lines and those tasked with litter picking and needle retrieval in toilets, parks and gardens, squats, and other locations where addicts congregate are frequent locations at which waste sector staff face the risk of sharps injury.

Now, the latest November 2012 edition of the Health Protection Agency publication ‘ Shooting Up ‘, clearly addressing issues of IDUs but trying hard to be politically correct in its – actually misleading - use of the term PWID.

PWID are vulnerable to a wide range of infections – including those caused by viruses such as HIV and hepatitis B and C, and bacteria such as anthrax and group A streptococci – that can cause significant morbidity and mortality.

Although the new report focuses primarily on hepatitis B infection, it also summarises data on other infections among PWID. The report’s key findings are that:

Hepatitis B infection among PWID has declined over the last decade. Overall around one in six PWID have ever been infected with hepatitis B virus
This decline most probably reflects the marked increase in the uptake of the hepatitis B vaccine among PWID over the last decade. Targeting vaccination to this group will need to be maintained if the current low level of new infections is to be sustained
Around half of PWID in the UK have been infected with hepatitis C. The prevalence of HIV among PWID remains comparatively low in the UK with around one in every 100 PWID infected
Bacterial infections remain a problem among PWID, with almost one-third reporting symptoms of bacterial infection (such as a sore or abscess) at an injecting site in the past year, and
Needle and syringe sharing is lower than a decade ago, although one-sixth of PWIDs continue to share needles and syringes

So hepatitis B is decreasing, and HIV is at around 1 in 100. That is, of course, reassuring, but now if you don’t know the origin of a needle stuck in you thumb and with an incidence like this high enough to warrant specific, and sometimes quite challenging preventative treatment and a long, long wait for the final all clear. And for hepatitis C, the rate is a more threatening 50%, higher still in Scotland, and shows no sign whatsoever of a decline in the last 2 years.

So, the risks are clear, hepatitis C, hepatitis B, HIV and a modest range of bacterial infections that even in a healthy individual can cause a nasty, perhaps life-changing, infection is associated with a large and soiled wound.

Prevention relies of hepatitis B immunisation, careful selection and use of PPE and associated tools, effective wound hygiene and prompt medical care in the event of injury or other exposure, and perhaps above all a sound common sense and careful approach to high risks tasks approached with a well thought out SSOW.

In the clinical environment, safety-engineered sharps are beginning to appear though there is perhaps some brinkmanship to avoid additional expenditure until the deadline for their mandatory introduction. And even then, there will be some non-safety sharps in use, necessarily retained for patient care in circumstances where no alternative is available. Most devices will be of the cheaper manually activated design that require the user to take some positive step to make these safe. With training, that should become a routine, almost robotic act but so too should be the placement of a used sharp into a sharps bin and even in hospitals that still doesn’t happen so don’t expect complete elimination of post-disposal sharps injury.

The provision of clean gear – new syringes and needles - to IDUs is a politically contentious matter. It costs money and money is tight, even more so when the moral majority would walk over hot coals to prevent a penny of taxpayer money being spent on this group. And of course many, about one sixth still share needles, increasing the prospect of disease transmission and contamination of a discarded needle. The reasons for sharing are many and complex yet often include heavy police intervention that make needle supply uncertain and unpredictable. That drives addition further underground and inevitably those dodging Plod will not want a big yellow bin that might as well be labelled “Addict” or more simply “Criminal”.

Regrettably, community sharps bin provision is as unlikely as the provision of clean needles, with many communities rejecting the placement of bins in toilets and high risk locations in parks and graveyards, preferring instead the scourge of discarded needles that someone else will have to pick up.

Blenkharn Environmental Led by Science Driven by Research

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Blenkharn
Environmental

Led by Science
Driven by Research