Segregation Errors | Blenkharn Environmental

Hospital hotels?

The press are today full of comment about hospital hotels, a new – at least new to the UK – initiative to use hotels as a half-way house for patients not quiet well enough to go home but good enough to move be moved out of a hospital ward.

It’s an idea predictably popular with Government and with the Department of Health since it frees much-needed hospital beds and todays news reports presumably represent a concerted political manoeuvre to test the waters of public opinion.

Hospital hotel transfers have been used in several countries already, most notably in Scandinavia, though an early trial at UCH London resulted in the unexpected and particularly embarrassing death of a patient while billeted at the local hotel. Continue reading “Hospital hotels?” »

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.

An ignominious end, before life has even begun

Care and disposal of the dead is becoming a hot topic at the moment.

In St. Paul, Minnesota, the Regions Hospital has admitted a second stillborn baby was ‘discarded’ in error and turned up in the hospital laundry.

“The hospital released that statement two days after acknowledging that the stillborn boy — who tumbled out of linens being prepared for cleaning Tuesday — came from the Regions Hospital morgue.

“The first baby — a stillborn, premature boy died April 4 at 22 weeks gestation. That body had been wrapped in linens in the morgue. A preliminary investigation found that someone mistakenly thought the bundled body was laundry that needed cleaning.

http://www.republican-eagle.com/event/article/id/87613/

Radioactive sharps bin contamination at Ninewells

An independent inquiry has been demanded after radioactive waste was wrongly disposed of at Ninewells Hospital.

Two weeks ago, a sharps bin containing radioactive waste was wrongly placed in a yellow clinical waste container. The radioactive material, which officials have stressed was not dangerous, was then sent out with the other clinical waste, against the conditions of the hospital’s site licence for the use of radioactive material.

The sharps bin containing radioactive waste was placed for uplift by janitors at stairwell 6, level 7 near the small lift in the laboratory block. This stairwell area temporarily holds all of the laboratory waste containers for level 7 until work on the freight lift is completed. An unknown person placed this waste in one of the yellow clinical waste containers, despite the waste being clearly labelled as radioactive.

[Stairwell? A temporary holding site for wastes? What about the fire regs?] Continue reading “Radioactive sharps bin contamination at Ninewells” »

Pharmaceutical residues from clinical wastes?

Regulators and those who follow on their every word continue to be exercised by the question of pharmaceutical residues from clinical wastes. Of course, bulk pharmaceutical wastes from the pharmacy department or drug manufacturing facilities must be managed with great care and their disposal must be properly controlled. There is, however, great confusion between this and the trace residues that might be present in soft clinical wastes and even in sharps bins filled with empty, or near entry, syringes. tablets and capsules

A recent conversation with colleagues in the US brought this issue once more to the fore. The proposal was that there exists serious environmental impact from empty syringes and the occasional tablet of IV bag in an orange (red) sack.

Taking this further, the conversation turned to the problem of scavenging of drug residues from clinical waste. When asked, that too was an environmental hazard since those drugs would end up in the environment, without control or proper disposal and treatment. The response perhaps bears repetition here:

Have you really swallowed the tale about the dire impact of drug residues from clinical wastes endangering the environment? That a few pharmaceuticals misappropriated from some insecure or unscrupulous waste management facility might precipitate environmental disaster? Or that outflows from domestic sewerage and/or solid wastes into which unwanted prescription drugs have been tipped will change the world?

Though it is no reason to ignore these sources completely, the impact is, without doubt, infinitesimally small when compared with excretion of the administered dose.

We cannot dispute that what goes in will come out, and actually quite quickly. On average, in excess of 95% of the administered dose of any drug is excreted unchanged, with some varying amount and range of metabolites. Half-lives change but most drugs begin to be excreted within a matter of hours and a single dose is usually eliminated within 24-36 hours.

We pass that into sewerage systems designed by Victorians to remove biological hazards but not pharmaceuticals. Yet when we find drug residues in natural water sources we get over-excited about a few street drugs and ignore the obvious.

Wastewater treatment processes are being considered for some hospitals, to reduce the burden of drug residues in their outflow. Quite right. But just why is this being done? Many regulators are taking the rather myopic view that this because hospitals are poor at segregation of pharmaceutical wastes. Yet they ignore completely, or simply cannot comprehend, that those same hospitals are full of patients receiving medications, defecating daily and urinating several times each day thus contributing a massive drug load to the sewer that conventional wastewater treatments cannot address. We make it worse still. Hospital staff are not immune from the need for drug treatments, from a simple cold remedy or painkiller, through to hormone-based contraceptives. And still regulators and those who hang on their words bang a drum for what are effectively the most minute contributions to the global environmental burden of pharmaceuticals, their metabolites and their degradation products.

To broaden the rather gloomy horizon still further, this is not restricted only to prescription pharmaceuticals but to OTC products also, though at least in the UK, and it seems elsewhere too, regulators cannot stretch their mind to this even greater pool of potential environmental contaminants but only to those prescription medicines defined by law and thus satisfying a naïve, or is it brainless, tick box mentality. Cleaning agents too, which though not considered in the same classes as pharmaceuticals share many similarities in biological and ecological impacts, in addition to more direct eco-toxicities.

Improvement in community wastewater treatment facilities may be advantageous, and particularly for outflows deriving from hospital ‘hotspots’. However, let’s not place blame squarely on the Victorian sewage treatment facility since globally many are lacking this basic public health resource and have to rely on cess pits, soak-aways or worse.

If that seems like a dipartite situation separating the have’s and have not’s, consider the veterinary and agricultural (livestock) use of pharmaceuticals . Globally, this is massive. It is largely unspoken as many developing countries use increasing but often undeclared amounts of drug additives to increase profitability in the global food markets.

At least some of us have the option to use a toilet. In the animal kingdom, mans intervention in the intensive livestock industries has not changed the inevitability of excretion directly to land.

Make your own mid up.

There should be concern about drug residues in the environment. When we stop over-prescribing, and curtail the sales of PTC (non-prescription) products, when we make arrangements for the collection of unwanted pharmaceuticals from households, when we stop passing out thousands of tonnes of pharmaceutical residues in urine, and start treating wastewaters accordingly, then there will be some significant reduction in the level of drug residue found in natural waters. The contribution from clinical wastes, and from drug litter, is infinitesimally small and regulators would do well to consider the science, and the logic, of the situation and divert their collective attention to the heart of the problem instead of making mischief around the periphery where their interventions will make little if any difference.

‘Recova wrap’ recycling scheme for the NHS

It’s the bane of many waste treatment facilities. Blue spun (non-woven) polypropylene wrap often ties its way around the best of shredders causing many hold-ups and some equipment damage during shredding of autoclave floc, and in automated feed systems for autoclaves, augers, microwave and incinerator plant.

Used for surgical drapes, the wrapper for sterile instrument packs, and for many single use disposable gowns used in theatre, radiology, in laboratories, and as the now universal disposable replacement for bed curtains that are found on every hospital ward, the material might be ideal for material recovery if separated effectively.

A new resource recovery service promises to do just that, but only for non-contaminated wrap. Strangely identifying itself as an environmentally aware non-profit .org organisation but nonetheless a limited company, Alternative To Landfill Ltd aims to be at the fore front of the recycling industry, concentrating on the recovery of waste for reuse, recycling and seeks alternatives for material that would otherwise end up in landfill sites.

Good for them. We are of like mind and would be happy to support their ideals. However, restricting the operation to accept only non-contaminated material is a serious drawback. Clearly aiming for the lower fruits, and avoiding the regulatory framework that might conflate operations that may then include wastes considered more accurately as clinical wastes, the problems that this may cause make the business model difficult to accept.

Chosen waste volumes must be low, especially since source segregation will permit recovery of non-contaminated feedstock for this operation only from the largest and most dedicated environmentally-aware surgical centres. They may be found centred around only the larger conurbations, leaving the logistics operation to bring together sufficient waste for a cost-efficient operation looking a little thin.

And of course, there is the thorny problem of source segregation. Will it be good enough? Will an item of miscellaneous plastic make a difference, or some stray sheets of paper? Probably not. But the ‘what if’ of contamination with some contaminated or bloodstained material is more difficult to predict.

How much contamination is necessary to define a contaminated load?

What about the contamination that is not visible? How hard should we look, among a skip full of compressed wrappers?

And once identified as contaminated, will the entire batch comprising multiple collections be rejected? And what becomes of that rejected material, since rejection must accept reclassification as clinical waste, consequentially bearing a high cost for disposal.

Mush spun or non-woven polypropylene drape and gown material finds its way to clinical waste treatment, and quite rightly so. The recovery of this fraction from autoclaved clinical wastes, after sterilisation and either before or after shredding, would be a major advance.

The developments of Alternative To Landfill Ltd are an important step forward and, at least in theory, looks to be of value though there are practical and operational matters of concern that may impact upon profitability and overall success. It’s a good idea, and if the regulatory framework permitted should be extended to seek the development of technologies to capture other non-woven wastes from ATT treatment floc.

Hospital recycles operating room waste into park benches

A Brunswick, Maine, hospital is reported to be successfully recycling operating room waste into park benches.

Mid Coast Hospital has launched a new recycling program that turns plastic waste from its operating rooms into park benches, trash cans and other items. Described by Mid Coast as the first of its kind in Maine, the program targets blue sterile wrap that’s primarily used to protect medical supplies and surgical instruments from contamination. The bulky wrap is clean when it’s tossed into the trash after being removed from surgical tools, but can’t be reused.

This is bulk waste produced in great volume. It can of course be sterilised as waste, but there is no logic in doing so. However, there will be good reasons not to place a black sack in the operating theatre, so what to do is sometimes a rather neutral question – there is only one option, to dispose as clinical waste. This means biting the bullet, to manage many additional bulky waste sacks that must not be compressed, and pay for its disposal at the highest rate.

So disposal as a clean recyclable is an ideal solution. Providing it is segregated reliably from used drapes and gowns that may be contaminate with blood, no further treatment is necessary. It is not, however, a failsafe approach to disposal and there can be few certainties about the elimination of bloodstained drapes from this waste stream.

Molly Gardner, left, Mid Coast Hospital’s linen and waste management aide, and registered nurse Jana Hentz-McDorr dressed up in blue-wrap items recently to educate the Brunswick hospital’s staff about a new recycling program.

Elsewhere, the separation from plastic residues from autoclaved clinical waste is technically possible. Latex gloves and non-woven polypropylene create difficulties but the technology works well enough to give a mixed plastic waste recyclate. It is unfortunate that the bottom has now fallen out of the market.

The use of Brunswick operating theatre plastic wrappings as the material source for bark bench manufacture is laudable. But always, someone will ask a tricky question and indeed I have had to deal with this. “What happens if…?”

Well, what does happen if blood from patient X contaminates the plastic recyclate? What happens if that is remanufactured to create a park bench and at some time in the future an arm is ripped off the bench and used as a weapon to batter a passer-by? Now, if the police seek forensic evidence to trace the criminal, will they discover DNA from patient X, and charge that entirely innocent individual with a crime the did not commit?

If you followed all that, you will realise that DNA will have been heated several times, to 138C and later to ~250C. In between, waste will have been washed thoroughly, and dried. DNA is a tough molecule, but unlikely to survive any one of those multiple treatment steps. Moreover, the DNA, should it survive, would be entrapped into the polymer matrix, not free on the surface, so the proposition that this commendable recycling process might place patients at risk of prosecution owes more to science fiction, and perhaps to CSI Miami, than to science fact.

So, if the process can work effectively, with segregated polypropylene wrappers of with mixed plastics from autoclaved, shredded bulk clinical wastes, even from sharps bins that might deliver a higher grade waste, then crack on. Regrettably, the Environment Agency would prefer such recycling to be dismissed from further consideration as it does not fit with their current ideology. Presently, even landfill deposit is a preferred option for much potentially recyclable clinical and offensive wastes that might feed energy from waste of cement kiln furnaces, plastics or fibre recovery, or methane generation. Instead, the options include landfill disposal and clinical waste incineration without heat recovery while neither should be on the list of acceptable options.

It will change, slowly, but the negative and generally obstructive attitudes of the Environment Agency, and current market conditions, stifle investment and inhibit translational research and commercial development.

Crack on.

http://www.theforecaster.net/news/print/2012/11/23/brunswick-hospital-recycles-operating-room-waste-p/143347

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.

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

Is that an elephant in the room?

Revision to legislation in the US State of New Jersey will prohibit health care institutions from discharging prescription medications into sewer or septic systems.

How that will happen is pretty straightforward – don’t discharge unwanted medicines into a sink or drain. But what of the patients themselves, and for that matter any of the hospital staff who are taking any medication, from a couple of aspirin, to anti-hypertensives or diabetes medications, perhaps even oral contraceptives?

Urinary excretion is the elephant in the room. It accounts for the huge majority of wastewater pharmaceuticals – assuming no inappropriate discharges of waste pharmaceuticals. But that latter scenario must now be unlikely. The discharge of narcotic analgesics and anaesthetic agents into a sink, to put them immediately out of use – from the anaesthetic room and operating theatre or in the intensive care unit, is now almost completely stopped. It was, at the time, probably the best option but with medicines disposal kits that are designed to receive and put these liquid medications safely beyond use disposal to sink is no longer needed. Indeed, this was central to teaching by Blenkharn Environmental some 15+ years ago and we take some considerable pride at being at the forefront of this change in practice, working with the Royal College [then Faculty] of Anaesthetists.

But what about those bulk wastewater discharges. We give medicines to patients. Those medicines are excreted [mainly] in urine, largely unchanged but in some cases with several complex metabolites. Urine goes directly, or via a catheter bag or bedpan/bottle, to teh swere and it should be no surprise that wastewaters will contain a vast diversity of pharmaceutical residues.

It would be interesting to look more closely at the presence of pharmaceuticals also in wastewater from the staff toilets. That will surely be less, and less varied, that that from patient excretion, but should equate more generally to the content in discharges from the community.

It is entirely correct that New Jersey should seek to formalise the prohibition of deliberate discharge of pharmaceutical wastes to sewer. However, that elephant cannot be ignored, when regulators puff and blow about the occasional tablet or capsule, or trace of liquid residue in an empty syringe or length of tubing. And of course, if those de minimis residues are of concern then so too is all that blood, presently overlooked as an additional source of pharmaceuticals. If a trace does really make a difference, then every trace makes that difference.

Targeted wastewater treatments to remove pharmaceuticals from hospital wastewater outflows is going to be a useful, and perhaps soon, an essential and mandatory process. It will carry a substantial additional cost.

This is not a solution for other wastewater discharges, from domestic premises. Here, only improved community wastewater treatments will make any difference. Reliance on largely Victorian wastewater treatment systems is simply no use. Though some developmental research is taking place, the water companies are supported by the Environment Agency to stop us polluting wastewater, without any attempt to deal effectively with pollutants that pass through their systems and out into our rivers.

And at the same time, other sections of the Environment Agency get anxious about trace residues resulting from occasional segregation errors, imposing ever more ludicrous guidelines for classification of what does, and what does not, contain drug residues. And every time they get it wrong, basing their ideas on the shaky foundations of inadequate knowledge and understanding, while failing to consider the available evidence and some simple realities of drug administration and excretion that we reiterate above!

How can we move forward? It is important to consider all discharges and not only those which can be easily targeted, certainly addressing the bigger issues and not fussing disproportionately about relatively trivial issues at teh expense of that elephant. More research is required, into the fate of excreted pharmaceuticals in wastewater discharges, and later as they pass into teh environment from sewage treatment facilities. Regulation should be predicated on significant, attainable and meaningful targets that have their foundation in sound science. That science must be interpreted with care, with transparency and, almost always, after discussion with a range of relevant experts to ensure that the conclusions drawn are meaningful and not based on the whim of an individual. We generally call that a public consultation; that must be transparent, and those responsible for its undertaking must prove their neutrality and demonstrate clearly that the conclusions represent fully consensus opinion. Where evidence is not available to support any decision, then it is appropriate to consider some intervention but to revisit that decision when better and more meaningful data becomes available.

In the meantime, the water companies and Water UK must step up to the plate and accept that demanding fewer discharges to help reduce their own efforts in wastewater treatments simply will not work. What is the alternative? Perhaps they would prefer that we piss up against the wall, in fact anywhere but into the sewer!

Why so much paper?

Many sacks of clinical waste contain substantial amounts of paper waste. Some of it is secondary wrappings from sterile items and I have not problem with that, since separation is inconvenient and may result in errors that place potentially hazardous clinical wastes into containers for domestic-type waste.

I have no problem with the occasional newspaper either, though would hope that better and more suitable waste disposal arrangements could be made available, perhaps to collect these domestic wastes from patients rather than having them use the clinical waste sacks. This latter is a particular problem since , in most cases, patients will try first to pull up the lid of the sack holder rather than use the foot pedal, contaminating their hands but rarely washing their hands afterwards.

Beware however bed roll waste. This has been disposed routinely to clinical waste sacks for no good reason. Indeed, in some hospitals significant volumes/tonnages of this waste are categorised as clinical waste for no better reason that a patient, perhaps fully dressed lay down on a couch for a brief examination or X-ray or ultrasound examination. This is clearly wrong and there is no need for this. Likewise, the disposal of paper towels at hand wash sinks, even in the clinical areas of a hospital. This too is unnecessary unless for risk management, space or other thoughtfully considered reasons black bags have been removed with ALL wastes going into clinical waste containers. The most likely circumstance, beyond space concerns being able to accommodate only one waste container rather than two, is when potentially hazardous clinical waste items have found their way into the domestic waste stream. Risk management will suggest training to reduce errors, but also of removing choice. In these circumstances, a Tiger bag will suffice, but why not treat and process these wastes for energy or resource recovery? Landfill is simply wasteful and inappropriate. That may comply with prevailing waste regulation but is wasteful and environmentally unsound.

The other common source of paper contamination of clinical wastes is confidential paper waste comprising generally just occasional sheets of paper containing some patient-identifiable information. Of course, it should be disposed in such a way as to acknowledge and preserve confidentiality. Shredders are rarely if every available on the wards, and a separate container for confidential paper waste is uncommon, takes additional space, and is not going to be immediately available when someone has a sheet of paper for confidential disposal – so off it goes into the nearest clinical waste sack!

Is that a problem? Well, probably not and if it preserves patient confidentiality in circumstances where the alternatives are unavailable or inaccessible and errors in disposal likely to occur, then I have no problem. However, the ubiquitous yellow or orange sack is not appropriate when there is a filing cabinet to empty and bulk paper waste must be managed more appropriately.

In the week’s BMJ, a news report notes that the NHS Commissioning Board has predicted that the NHS will be paperless by 2015 with paper records “eradicated” by this time. Some it is rather ambitious, while the Board is pushing hard for developments that will improve efficiency, ensure transferability and access of records at any location, between hospitals and GPs and save the need for the vast amount of correspondence items that move back and forth between different care providers and locations.

It is not clear if this will work, I suspect not, but it is a step in the right direction. Will it reduce clinical wastes being contaminated with confidential and other paper wastes? Certainly not, though the former may one day be reduced in volume. As it does however, the justification for a shredder, or a confidential paper waste box, a porter to collect, and a separate disposal contract, will become economically unviable. So the net result may be, at least during the transition period, a net increase in the amount of confidential paper waste finding its way into clinical waste containers. Live with it.

Lies, damn lies, and statistics?

Daniels International are now evaluating their Clinismart system in the UK and elsewhere. Surrounded by the full range of ‘in your face’ advertising that has been a feature of Daniels Sharpsmart system, some of the claims made so far need careful consideration, a big pinch of salt and a great deal of scepticism.

The UK evaluation, at University Hospitals North Staffordshire NHS Trust, is described in some little detail in a recent article published in Inside Hospitals. Related advertising copy includes a glossy Sterihealth brochure that makes the most ridiculous claims about this system:

Terry Grimmond, a Microbiologist for Daniels, states:

“ The Clinismart cleaning process was tested by coating bins with 6-log blood-suspensions of Staph aureus, E. faecalis and Mycobacterium phlei. On swabbing them after the wash, not a single pathogen remained. The risk of infection was less than 1 in 100 billion!”

That is bad science. It is nonsense science. It is simply rubbish, to equate the results of some unconfirmed in vitro tests of pathogen survival on hard surfaces with the potential for infection. And 1 in 100 billion? 1 in 100,000,000? If you killed 10⁶, 0r 1,000,000, pathogen cells how does that correlate to a risk reduction of 10⁹? Quite simply, and by a very substantial margin, it does not.

It would be appropriate instead to consider the inherent risk of infection with a conventional system and then by epidemiological study assess any change to the infection rate in a suitably controlled long-term study after introduction of Clinismart. If any risk exists, though we all agree that it does, it has not been quantified and probably cannot be quantified even in the most rigorous of scientific studies. That is no reason to dream up such silly claims that we read about Clinismart.

Other bold and prominent advertising copy includes:

“Reduces infection transfer“

How does this system “reduce infection transfer”, and for that matter what on earth does “infection transfer” mean?

“Using a foot-pedal opening mechanism and a bagless system now means hand contact with the collector is no longer required. This results in a dramatic reduction in the infection transfer risk that currently exists with standard clinical waste collectors.

Back to this nonsense of infection transfer risk?

If they refer to contamination risk, that is a completely different thing. This might be true for the ancillary staff and waste handlers, for whom contamination events and related infection risks are a sometimes understated risk, but this is no different from the pedal operated bin holders used by healthcare professionals when placing waste into a clinical waste container. Except now, they must first wheel the Clinismart clinical waste container to the bedside.

That can only happen if nobody else is using it, and on a 30 bed ward several of these will be required. Where will they be stored? Will we wheel a non-clinical equivalent container to the bedside also, or place those other wastes into the Clinismart system, thus defeating the key purpose of this system? And with all those waste containers wheeled to the patient’s bedside, will there be any room left for the patient?

The implied claims that this Clinismart system will eliminate hand contact by use of a foot operated pedal may be true for the user, though as we note above this is equally true for conventional bag holders also. But how does the Clinismart move from point A to point B, and C, and D and onward around a busy ward? Do we kick it, aiming a toe at the Clinismart foot pedal? Or does the user push it, by hand, defeating by necessesity one more of the key claims made for the system?

“…each container is removed from your premises, emptied, and then subjected to a rigorous 6-stage wash and sanitation process. This process is so effective that the risk of infection from a returned empty collector is less than 1 in 100 billion!

Oh no, back to this ridiculous claim of a 1 in 100 billion risk of infection”

Daniels may have a useful product in the Clinismart system, and until there is a body of fully independent user feedback and analysis we should hold our breath – wait and see, in the hope that some properly peer-reviewed and independent assessments from more than one centre and more than one assessment group are available for scrutiny.

However, the ridiculous claims made make a mockery of microbiological science and would, in the UK, fall foul of the ASA guidelines that require advertising material to be legal, decent, honest and truthful. So far, these claims in my opinion fail on at least 2 counts and thereby presumably fail on the legal count also. Since this document is available via the internet and thus in all countries worldwide we should be concerned, but the web address is Australian and we will leave it to the Australians to decide.

In all other respects, we must Ask for Evidence of these bold and misleading claims.

Ian Blenkharn

Sharps waste found in domestic refuse from UK hospital

Basildon Hospital is under investigation for failing to properly dispose of potentially hazardous medical waste, including used syringes.

The Environment Agency are ‘probing’ how syringes and other equipment used to drain bodily fluids from patients, as well as other used medical supplies, made it into the general waste and from there to a Veolia recycling centre!

Veolia Environmental Services, which removes the hospital’s general waste, discovered used equipment was being thrown out with the rubbish this month. An Environment Agency spokeswoman said: “Regulations are designed to ensure different wastes are dealt with in appropriate ways to protect the environment and human health. “We are investigating the destination of waste from the hospital.”

A Veolia whistleblower said: “The hospital failed to spot dangerous contaminants in clear rubbish bags and failed to check before decanting it into a large loader.

http://www.echo-news.co.uk/news/9937827.Used_syringes_thrown_in_hospital___s_rubbish/

Though rarely identified this type of problem occurs more often that is generally realised. Waste audits have become part of the routine of clinical waste management. As we have criticised bitterly on many occasions previously, almost all audits focus on the content of clinical waste containers, often finishing with indignation about the presence of a few sweetie wrappers or an empty drinks can in a yellow or orange sack. That simply does not matter!

Of concern is the finding of rogue wastes in black, or clear, general waste sacks. Clear sacks aid recognition of these fugitive clinical wastes, but in black sacks nobody will know unless there is a sharps injury or blood spillage. By then, it is too late.

Clear sacks are a great idea, but so too is the inclusion in regular waste audits of the composition of wastes in black (clear) sacks as this gives a better indication of segregation standards.

And though the trend is to ever more source segregation, there is another option. In clinical areas including wards and ITU, operating theatres, some laboratories and pharmacies, black bags can be removed entirely. With all but primary packaging waste removed for separate disposal, the system is largely fail safe for all but stray sharps placed into a waste sack. The amounts of domestic type waste generated in a busy surgical ward is modest at best, and its disposal with clinical wastes is fail safe, environmentally sound and of little economic impact.

As an aside, at Basildon the investigations may perhaps find a culprit. Will there be robust disciplinary action taken?

With increasing concern about pharmaceutical residues on drug packaging waste, the management of these wastes with all other pharmaceutical waste will soon be upon us. We have proposed before these developments, of waste audit to encompass examination of non-clinical waste containers, and of the removal of black bags from clinical areas. We will continue to do so.

With developments in materials or energy recovery from treated wastes, this approach becomes even more practicable. Watch this space.

Reusable sharps containers

We are becoming accustomed to re-usable sharps containers, not least because of the bullish advertising of their sole manufacturer.

But now, there might be a new kid on the block. One that is cheaper – I presume – one that is far more simple and without reliance on a possibly over-engineered mechanism with in-built resilience for many cycles of use.

Rehrig Pacific Co.’s Sharps Tank is an FDA 510(k) cleared, 17-gal. reusable sharps container that may be used in clinical and laboratory environments for the disposal of both small and large sharps.

It has been FDA cleared as a Class II Medical Device and is also DOT approved, PGII rated for bio-hazardous waste collection. Unlike single-use disposable sharps containers, the 100% recyclable and reusable Sharps Tank is both economically and environmentally sustainable with a life cycle of hundreds of uses.

Works in areas with limited space and includes a wide opening, side-hinged main lid and a transparent sub-lid for more restricted access and monitoring fill capacity. Each lid has a two-position latch; one for daily use, the other a full lock position for transport. Optional accessories include a hands-free foot pedal dolly and a molded four-caster rolling dolly designed for the clinical environment.

Tank is designed for automated handling and is nestable for efficient shipping and storing when empty. The high-density polyethylene main lid and container along with the polypropylene sub-lid are made with an antimicrobial additive for additional clinical protection.

It looks like a standard container but one with, one presumes, a removable and re-fixable lid. However it looks, it may be a cheaper option that the present player in the reusable market. Perhaps the difference will be in the reliability of reprocessing processes, and the number of cycles of use possible for each container, and the means of tracking to ensure no container is used excessively.

Importantly, it looks like a standard waste bin, is compact and stackable. Scaled up, perhaps it will be a suitable replacement for the standard sack and sack holder?

The new Clinismart system which is positioned as a shared resource to be moved around a ward or clinic may have significant drawbacks. But this much simpler system, as a direct replacement for each existing waste sack and holder may offer a degree of flexibility and practicality, with cost savings against staff time and the cleaning necessary of fixed sack holders. This may be a model for future development.

Colour coding of clinical wastes from domicillary care

The selection of colour coding for clinical waste containers, dictated by the notional properties of those wastes and in particular the risk of infection – yellow or orange – is rather straightforward, though as we have discussed many times previously not entirely logical in its rationale. Leaving that aside, most wastes will be categorised as not being of particularly high risk and will be bagged in orange.

Not so in Derbyshire Dales District Council where yellow is still the only choice. As for so many other local authorities, the change from yellow to orange just seems to have passed them by. It is difficult to envisage any possible risk assessment however generalised it might be that could justify this.

It is not an isolated occurrence. Indeed, many local authorities – as demonstrated once more in the 2011/12 local authority clinical waste audit – take a similar outdated view on colour coding, which sits uncomfortably against their sometimes bullish attitudes toward even the slightest error in householder segregation of recyclables. Waste contractors seem not to mind. The Environment Agency takes no notice and continues to sit on its hands, oblivious to the mess that is clinical waste segregation and coding, a mess that is of its own making.

http://www.derbyshiredales.gov.uk/environment-and-waste/waste-a-recycling/faqs/clinical-waste

Plastics recycling from healthcare wastes

The Healthcare Plastics Recycling Council (HPRC) has finalized an agreement with Stanford University Medical Center to begin a six-month pilot study to develop a better understanding of plastic waste characterization within healthcare facilities. The study will collect and analyze data related to materials, types, volumes and sources of pre-patient plastic waste at Stanford Hospital and Clinics in Palo Alto, Calif.

“This pilot work is momentous as we work towards our mission of inspiring and enabling sustainable, cost-effective recycling solutions for plastic products used in the delivery of healthcare,” says Tod Christenson, director of HPRC. “The information captured from this study will provide valuable insight into the barriers and challenges of recycling mixed plastics in hospitals. From these learnings, HPRC can then contribute meaningful fact and experience-based guidance on plastics recycling to other healthcare facilities.” Continue reading “Plastics recycling from healthcare wastes” »

Complains about appalling state of hospital toilets

Toilets at the at the Royal Cornwall Hospital were in an “absolutely disgusting” state, according to a patient. Continue reading “Complains about appalling state of hospital toilets” »

Managing Norovirus waste

Norovirus outbreaks continue to be a major seasonal problem and cause huge disruption to care services with substantial morbidity and mortality. What to do with Norovirus waste?

Much waste will be destined for the toilet or bedpan washer/macerator and though this creates a substantial risk of further aerosol distribution that is a matter for another day.

Inevitably, there will be large volumes of solid waste for disposal, much of it wet waste, and the ubiquitous plastic sack may be less than adequate. Double-bagging may reduce the risk of leakage but when large volumes of wet waste require disposal a rigid bin should be used as these have tight fitting lids that resist leaks and will not be compressed as they pass along the disposal route.

Some guidance exists. Compiled by HPA together with others, Guidelines for the management of norovirus outbreaks in acute and community health and social care settings offers much practical guidance on the management of Norovirus outbreaks. Sadly, waste management is largely ignored, presumably on the basis that once it leaves the ward the wastes are of no further concern. But that is not so; several cases of Norovirus infection have been recorded among waste handlers and it is likely that the true number is considerable. Regrettably, this latest document confuses healthcare waste and clinical waste and uses the two terms interchangeably. No further detail is provided. Continue reading “Managing Norovirus waste” »

Hospital worker makes needlestick compensation claim

9th May 2012

Suffering a needlestick injury can be extremely distressing for anyone affected. Solicitors recently represented a hospital employee who was injured at work in this way and he received compensation.

Safety Procedures not Followed

The IP was emptying a clinical waste bin at his workplace. As he lifted out the bag he felt a sharp pain in his finger and realised that a needle inside the bag had penetrated his gloves and punctured his skin.

The needle should not have been put into the clinical waste bin, as there was a dedicated container for needles and other ‘sharps’ in accordance with health and safety regulations. Continue reading “Hospital worker makes needlestick compensation claim” »

Couch rolls

I had the misfortune of a hospital appointment yesterday, for a series of tests that too place in a modest sized room equipped with an examination couch and a whole array of electronic equipment.

Shoes and socks off. Trousers rolled up around my knees, and top two buttons of my short undone.

Sat initially on the edge of the couch it was equipped with a nice clean pillow and cotton pillowcase, and a cotton sheet folded to create a pleasing strip down the centre of the couch, from over the head to beyond the end with carefully crafted style that might please the eye but achieved little else. Continue reading “Couch rolls” »

Source segregation – getting the process right

Much is said about source segregation of waste from clinical areas. A sometimes apoplectic response can be expected when inappropriate general waste items are found in an orange or yellow clinical waste container. Penalties are threatened and sometimes imposed by regulators who might sidestep direct action against producers in favour of a cheap swipe at waste management service providers who have little control over initial disposal processes and procedures. Continue reading “Source segregation – getting the process right” »

No wonder it’s so bad

Clinical waste management in the clinical environment should be managed to an exemplary standard in order to maintain hygiene standards and eliminate the hazards associated with sharps and sharps injury. But is that always so good?

A flurry of comments on the PracticeNursing.co.uk web site suggests otherwise. Nurses who do not want to make the effort, and who might accept no responsibility for wastes but wish others – the cleaners – to manage it for them paint a miserable picture of unprofessionalism. That reflects badly on those individuals, and others, and is probably more reflective of common standards of waste management than we would normally care to admit.

With attitudes like this, it’s no wonder source segregation does not work.

Recycling with sponsorship

The beleaguered NHS wastes money with a passion but is nonetheless underfunded and chronically short of resources. Healthcare waste management reflects this, with much waste of material and cash resources worsening an already difficult situation. Continue reading “Recycling with sponsorship” »

NICE clinical guideline – primary and community care (waste management)

The National Clinical Guideline Centre has released its latest and probably last draft of its document “Infection: prevention and control of healthcare-associated infections in primary and community care” for pre-publication check of factual errors.

The guide includes a long-winded section on waste disposal. It says little that is new. In fact, it says very little indeed since it refers to, but does not go as far summarising the guidance of HTM 07-01.

New in this 2012 guidance is the comment that healthcare staff should “Educate patients and carers about the correct handling, storage and disposal of healthcare waste“. Continue reading “NICE clinical guideline – primary and community care (waste management)” »

Sharps injury prevention for hospital workers

A potentially interesting paper published recently in the International Journal of Occupational Safety and Ergonomics reports the incidence of sharps injuries in hospital staff in Turkey.

Though the journal is inaccessible at present as it sits behind a firewall the abstract tells of sharps injury occurring in one hospital collected between January-October 2008 using Adverse Event Notification. Continue reading “Sharps injury prevention for hospital workers” »

Regulator bites!

“Scripps Health and Sharp Memorial Hospital have settled separate civil lawsuits with the county District Attorney’s Office for improperly disposing medical and hazardous wastes, including human blood and tissue, in the Miramar Landfill.

“The District Attorney filed the lawsuits after both Scripps and Sharp received multiple citations over two years for improperly handling, transporting and storing medical wastes both at the hospitals and at the landfill. Continue reading “Regulator bites!” »

US hospital saves $100,000 with ‘green’ practices

The Johns Hopkins University Hospital has saved $100,000 over a number of months by reducing its medical waste by 16 percent and by putting it in the correct containers.

“Red bag” trash, which is regulated medical waste, costs Hopkins about $.25 per pound, while clear bag waste costs the hospital $.04 a pound. Putting waste into the correct waste stream saves money. Continue reading “US hospital saves $100,000 with ‘green’ practices” »

Cutting through the ….

Advertising flimflam is usually quite obvious. Bold and exaggerated claims and highly selective quotes clipped out of context are usually easy to spot. The law says much about the use of spurious advertising claims, and quite rightly so; such cases should be infrequent, if not rare. However, we should take all advertising claims with caution.

“Caveat emptor” or ‘Let the buyer beware’ is an essential maxim, but how does this affect us on the Clinical Waste Discussion Forum? Continue reading “Cutting through the ….” »

Tissue waste disposal

Tissue waste disposal is a sometimes difficult issue, since patients may have their own view on disposal, perhaps of an amputated limb, or of a placenta, than do healthcare professionals. Continue reading “Tissue waste disposal” »

£20k savings on clinical waste disposal

Northampton General Hospital claims savings of around £20,000 on clinical waste disposal through their initiatives to drive enhanced source segregation and exclude inapproriate items into clinical waste containers.

“We’ve asked staff to think about what they put in the yellow sacks because it costs up to four times as much to dispose of those and we’ve saved about £20,000.

“The hospital’s sustainability programme aims to reduce waste, increase the efficiency of buildings and minimise energy and water consumption.

“In recognition of its efforts, NGH has been given a gold National Recycling Stars award, but hospital bosses hope the scheme will save it £250,000 over the next two years.

Such efforts are rightly rewarded, and tthe savings make a huge contribution both to environmental impact and to the balance sheet.

Unfortunately, several issues are studiously overlooed when reporting such schemes. How much did it take to operate, and will the savings be sustained without the constant, and costly, input of wste managers and their team? This is not the first, and probably will not be the last such scheme operating in thsi way, reported through the trade and popular press or approached as an acdemic study and published in a scientific journal.

What happens is that a relatively short term burst of intense input topward improved waste management yields immediate savings that are multplied up to obtain the headline figure for annualised savings, but when the input is removed savings fade away and cannot be sustained. We are not told how long this initiative has run – though the report does refer to savings accrued ‘in the past year’ - and whether the savings are real or simply annualised. If the figure is accurate, what has been the cost of delivery? And even more imortantly, was the saving bolstered by wholesale down-regulation of wastes?

The other problem is that rarely if ever does anyone look at the flipside of these ‘waste managemnt drives’. How many incidents of waste segregation errors were there? So much effort is directed toward exclusion of innappropriate items from clinical waste containers that many items which should be disposed into this waste stream find their way into another, and wholly inappropraite, waste container. Of course, that is cheaper, but dangerous and contrary to the regulations. A fine or compensation claim would wipe away these notional savings at a stroke. Did anyone look for this? Did the rate of these segregation errors (clinical waste → black bag) increase?

All credit to Northampton for their work, and congratulations on their award. However, without much more detail the success may in fact be rather shallow and unsustainable, and the savings more apparent than real.

Blenkharn Environmental Led by Science Driven by Research

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Blenkharn
Environmental

Led by Science
Driven by Research