Clinical waste sacks generally come in one size only. Large. Though smaller sacks are available, these carry a price premium and are likely to necessitate purchase of separate sack holders so these are not a viable economic option.

A “trial” to replace standard clinical waste sacks with much smaller ones – an attempt to force waste generators to think about what they were disposing – was a failed attempt to reduce clinical waste volumes [forced into black sacks, presumably!] and quite predictably fizzled out.

Big waste sacks

So, we’re stuck with big sacks. Sacks of considerable capacity that are rarely filled with clinical wastes. Instead, they tend to be filled waste paper towels – an obvious consequence of locating clinical waste sacks next to the wash hand basins – and couch roll. However, in most wards and departments, dentists and GP clinics etc, waste volumes are small and clinical waste sacks of whatever classification accrue only slowly. So, how often should these be changed?

Many IPC teams claim that waste sacks must be changed every 48 hours at the most, though they are able to realise that such recommendations do not work for sharps bins and keep quiet when challenged to justify a 48 hour rule, and the contralateral rule that ignores sharps bins.

Why 48 hours

So why 48 hours? The idea comes from a combination of factors. Some would like to believe that after 48 hours a bag part-filled with clinical wastes will become smelly and thus should be replaced. Others perceive some additional infection control concern, but are unable to explain this when challenged. Still others believe that its just the right thing to do. They don’t know why but its what others do, so why not. Like sheep, they follow the crown and soon it becomes a ‘standard’.

The reality is no smell, save for the nature of the contents of the waste sack. If some smelly waste is placed into a waste sack it will smell, same day, next day, every day. It’s unlikely to become more smelly over time, though awareness may increase. If it smells, change the sack, whenever that is necessary.

In many clinical areas, regular cleaning of waste sack holders is part of the hygiene routine. These will probably be given a wipe down daily, with a more extensive wipe down at least weekly. That hygiene routine is important, for entirely regulatory purposes, as part of a professional approach to hygiene management, but perhaps not as a measure to prevent infection. Clinical waste sack holders and the waste sacks which they support are, should not be, touch surfaces at all and thus the transmission of infection to the hands of a user is difficult to comprehend. However, it is depressingly common that users do handle the lid, to lift this by hand instead of used the foot pedal. That is bad practice, but one which is difficult to eradicate. Therefore, daily sanitation of the bin holder, as something of a rear-guard action to promote infection prevention, is entirely rationale, though not necessarily so in areas where clinical waste sacks are used infrequently.

A rational approach to infection prevention?

It is far from popular, but identifying flaws in a system highlight effectively the lack of value in rules that are incomplete, misleading, and meant to be ignored. Many who promote the daily cleaning of waste sack holders baulk at the suggestion that such a policy might ever be relaxed. Regrettably, those managing infection prevention in the community follow this lead and seek to bully GPs and dentists to the same standard. But take these IPC staff to the outpatient department and show them a waste sack holder in one of the many consulting rooms as ask them how often they are cleansed. Weekly perhaps, if you’re lucky.

The exception to the rule. Does it suggest that the approach should be risk based, with separate guideline cleaning standards for different areas? Daily in high risk areas, and less often where the risk is negligible? That isn’t too hard, and there is no reason to treat everyone as fools, with a pretence at an all-embracing standard which is knowing ignored in many areas.

Back out in the community there can be no doubt that those sack holders should be clean, but daily wiping down of a clean sack holder is of doubtful value, is unproven by any research assessment, and is perhaps a diversion from more important cleaning tasks.  Make a decision and some guidelines. Define a minimum standard. But one size does not necessarily fit all. It is not cost-effective. It is not necessary.

Clean as you go is an important concept and should be factored into all cleaning standards and the mindset of all healthcare teams, If a waste sack or its holder becomes soiled, clean it. Clean it promptly. What tends to happens now is that this waits until the next routine cleaning cycle, an entirely mindless and unprofessional approach

How to clean a sack holder?

This is not the place to find a detailed guide on the routine cleansing of sack holders since much will depend on other cleaning procedures, the range of cleaning products available, and the materials of construction of the sack holders.

Routine cleaning of the external surfaces of the sack holder might be limited to the lid only. This is the only likely touch surface – though it should never be a touch surface – and attempts to clean other surfaces of a daily basis are probably necessary unless these are visibly soiled.

Though it is often overlooked, the sack holder should be moved (carefully) to enable the floor under and around the area where it stands to be cleaned, of any dropped waste items, dust and dirt, and damp mopped with careful spot cleaning of any splashes or spillages.

The catch is in the safety of those who are cleaning. They must wear suitable gloves, colour coded Marigolds would be appropriate.

If there is ant likelihood that the cleaner will touch the waste sack then disposable gloves would be more appropriate since a pair of Marigolds contaminated through contact with the sack would be a concern if these are used then to clean other locations, spreading contamination as they go. In routine practice, there need be no contamination, for example when he lid gets a quick wipe over.

Anything more, and in particular of the inside surfaces of the sack holder then yes, the sack should be removed and replaced to keep safe the cleaner. That would be an obvious precaution, even if it requires early disposal of a waste sack that is only part filled.

So, how often to change waste sacks?

Risk assess it. Don’t think about a formal written assessment or some complicated scheme, but train staff to manage sacks and their holders on a common sense approach, with minimum standards set for areas of different risk, and a comprehensive audit process for hygiene performance in all areas itself varying in frequency and extent depending on overall risk.

In some areas such as ITU and theatre, waste sacks will be changed at daily intervals and between every patient. That has become an established routine. However, the sharps bin will remain, overlooked in the great scheme on things and making nonsense of the rule.

Train staff to be aware of hygiene requirements, to report deficiencies, and to act properly when any item of equipment needs attention.

With that approach, that would be entirely acceptable to regulators if properly structured and supported by effective training and supervision, and periodic audit. In high risk areas, change sacks daily. Waste down sack holders at the same times. For others, the frequency can be much reduced, and for low risk, low waste volume areas such as GPs and dentists, there is no reason why an almost empty waste sack cannot remain in a clean sack holder for many days or weeks, or even longer.

And sharps bins too?

The obvious rejoinder to this is what to do about harps bins. Don’t change them at set intervals as some suggest. That is a waste of money, in the cost of bin supply, and in disposal.

Choose a bin of a size appropriate to the volume of waste that might be predicted, but don’t waste more money by retaining stocks of many different sizes of sharps bin when just 2 or 3 sizes at most might be appropriate.

Use the bin for its intended purpose, and not as an all and sundry waste container. There will be no smell. Use the temporary cover when not in use.  Replace when about 2/3 to 3/4 full unless the bin is soiled in which case it should be replaced sooner.

It is inappropriate to wipe down the outside of a soiled sharps bin, except with the greatest of care. If this is to be done, and hopefully it will not be necessary, then a) treat the container as contaminated and high risk but clean it in situ. Don’t carry it to another location to be wiped since that creates additional risks. Do not attempt cleaning unless b) the temporary lid is properly closed. Only light cleaning is appropriate c), with any more aggressive cleaning being inappropriate and instead a pointer that the bin should be discarded and replaced. And finally, d) clean the entire area in which the sharps bin was standing, since this too is likely to be soiled. We have a publication Blood splashes around sharps bins: hygiene failures in the clinical environment? which can be made available on request.

How often to change waste sacks and bins from the clinical environment is perhaps the single more frequent question that we are asked. The concept of routine changing of all waste sacks at 48 hours has spread like a Chinese whisper, but is without foundation and in most cases quite unnecessary.

Train staff; increase and maintain awareness; establish rules as general guidelines only, risk assessed and proportionate. Ensure an effective procedure to report and manage any soiling without delay, don’t wait until the next routine cycle. Audit and record.

In the process, save time and money in disposal. Quite how much is difficult to predict, but for the small and occasional waste producers such as GPs and dentists, waste volumes are so small that the entire frequency of waste collections could be substantially reduce.