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Published on 9 June 2010

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Sharp thinking

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The hospital pharmacist can play a pivotal role as gate-keeper to ensure the safe use and disposal of sharps used for self-administered therapies

J Ian Blenkharn
CBiol CSci FRSPH
Blenkharn Environmental
18 South Road
Ealing
London W5 4RY

Safe working practices reduce, but have sadly failed to eliminate completely, all sharps injuries and regrettably incidents continue to occur. The immediate physical impact of sharps injury may seem trivial but it carries a risk of pyogenic infection and in extremis transmission of an ultimately fatal bloodborne virus (BBV) infection. Some basic steps in sharps safety are given in Table 1 and though these simple measures may seem self-evident, comprehensive training and supervision remain essential.

Sharps disposal must coincide with a central hospital waste policy and in the UK should additionally conform to the requirements of HTM 07-01.1 Sharps bins must be colour coded to segregate wastes contaminated with pharmaceutical residues (yellow), cytotoxic or cytostatic wastes (yellow with purple) and wastes not contaminated with pharmaceutical residues (yellow with orange). The content of syringes and bags should be expelled for separate disposal where it is safe to do so. Drug wastes not inside sharps should be collected separately; it is often tempting to use a convenient sharps bin and if destined for disposal by incineration there is no advantage in further separation other than to permit more precise waste categorisation and to satisfy regulatory objectives but this requires prior liaison with the site waste manager and contractors.

Where opportunities exist for resource recovery, source segregation of wastes is key to success. Environmentally sensitive disposal employs non-incineration waste treatments with post-process materials recovery. Careful risk assessment is essential at each stage in the disposal process; users must not be tempted to cut or disassemble used syringes, bags and tubing to separate plastics from sharps waste as this risks injury and personal or wider environmental splash contamination from the drug residues within.

Sharps bins must be of a size appropriate for the amount of waste expected. Bins should have a wide mouth to accept with ease all waste items. Some bins have a needle removal device moulded into the lid but this should never be used; syringes and needles should always be discarded intact. It is good practice to secure bins using a retaining bracket.

Sharps bins must be securely sealed for disposal when no more than 2/3- 3/4 full. Every bin carries a fill line but as bins are invariably opaque this requires a little common sense. The temptation to shake an almost full bin to create additional capacity or to force another item into a bin that is already full must be resisted as this increases the risk of injury. Overfilled bins are particularly dangerous and should incur disciplinary action.

Sharps bins likely to be contaminated on their external surfaces must be bagged to protect those who come into contact with them as they pass along the disposal chain. Using forensic techniques, trace blood residues can be detected on the outside walls of around 40% of sharps bins from acute clinical areas, with additional contamination on the wall and bench top where they had stood. If this is indicative of the difficulties of placing tubing items safely into the bin without risk of contamination then the same must be true also for items used in the preparation of cytotoxic products underscoring the need for great care in disposal.[2] This is confirmed by evidence from specific monitoring procedures[3] that might be extended to include the external surfaces of sharps containers. Contamination may not be eliminated even with automated systems;[4] waste containers removed from a sealed environmental chamber may still carry fugitive drug residues on their external surfaces, placing ancillary staff and waste handlers at risk.

Bins with a deep recessed opening are preferable to simple cylindrical bins with a flat top and horizontal sliding closure. The deep funnel-like opening of these bins helps guide items during disposal, while the latter offers little protection against contamination when  attempting to steer a length of tubing with attached needle into a small aperture.

The substantial quantity of high grade plastic accumulating in sharps bins makes material recovery an environmentally attractive option. The regulatory situation is uncertain. In many jurisdictions, concerns regarding de minimis pharmaceuticals concentrations in even fully discharged syringes create a barrier to recycling, requiring in most cases disposal by incineration. These barriers are perhaps founded more on ideology than science; drug residues in the effluents from non-incineration waste treatments may be infinitesimally small and have no environmental impact which sits uncomfortably against residues present in other empty drug containers that are routinely recycled but disregarded by regulators. Despite the obvious advantage of material recovery and reuse, environmental protection must be measured in a balanced way that considers and controls the quality of source segregation and the practicalities of supporting multiple waste streams that must be managed hospital-wide to be commercially attractive to waste contractors.

Though sharps injury is often considered as a particular risk for clinical and nursing staff, hospital ancillary workers including porters and cleaners are at proportionately greater risk with sharps injuries in this group around 10x greater than for nurses and 30-40x more common than for clinicians.[5] These groups are at the mercy of healthcare professionals, including pharmacists. Discarding a used needle or other sharp item into a thin-walled clinical waste or general refuse sack intended only for soft wastes is an inexcusable error but one that occurs frequently.[6]

Mandatory reporting, audit and review of sharps injuries are essential to support the advancement of safe systems of work. Policies for the safe use and disposal of sharps and a sharps injury policy which also addresses injuries to those handling cytotoxics are essential. Policies must specify the steps required in the event of injury. They should be compiled in consultation with appropriate clinical specialists, effectively publicised and integrated into staff training programmes.

Under-reporting of sharps injury is common and staff must be encouraged to comply with injury reporting requirements. Sharps policies must encourage and support incident reporting to facilitate access to post-exposure prophylaxis (PEP), early referral for specialist care and comprehensive follow-up. Policies must operate effectively outside normal working hours; there must be no barriers to the immediately availability of PEP. Even where the risks are low and seroconversion unlikely, the impact of a sharps injury can be devastating. Debilitating post-traumatic anxiety disorder is not unknown after sharps injury whether or not seroconversion occurs necessitating prolonged counselling and support before return to work. Some may feel unable to return to normal duties if this entails use of or exposure to sharps which will require careful and sympathetic management to support the individual and mitigate any compensation claim. Sharps injuries involving cytotoxic or cytostatic drug exposure create additional difficulties and suitable protocols must be devised for immediate first aid and follow-up care. All incidents must be recorded and investigated thoroughly, to identify and report equipment failures and review drug handling procedures, and to refine and enhance safe systems of work.

The correct choice of equipment for preparation and administration of drug products is essential. The pharmacy must be central to the construct and review of drug administration policies. The extent of influence and involvement should include equipment selection and procurement for all injection and infusion supplies.[7] Safety and performance are key criteria but packaging and material composition and ease of disposal are important practical and environmental issues that must not be omitted from the selection process.

Sharps injury rates may be reduced considerably by use of safety injection equipment or retractable needle devices but these are expensive and not suitable for every situation. Notwithstanding, the provision of medical devices incorporating sharps protection is mandated under EU Directive 2000/54/EC. A recent directive (08/03/2010) additionally implements in law a framework agreement on prevention from sharps injuries in the hospital and healthcare sector. This directive will be transposed into national law by EU member states within the next three years.  It requires needle safety devices, risk assessment and the modificationof work practices that pose a risk of sharps injury,prohibition of needle recapping, and mandatory training in the safe use and disposal of sharps. There seems no reason to wait, and hospitals should consider early implementation.

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This changing EU legislation may require modification of pre-loaded syringe-packaged pharmaceutical products perhaps necessitating long and complex, and inevitably costly, revalidation and relicensing of products. Patients and their carers, and the healthcare professionals who support them, will need training in the use of the modified product. Outpatient prescribing of injectables for self-administration should additionally include checks on the supply of a suitable sharps bin and arrangements for its collection and disposal, and the supply of a suitable replacement if required. This is a common area for error on the part of prescribers and/or community care services.[8] The hospital pharmacist can play a pivotal role as gate-keeper to ensure the safe use and disposal of sharps used for self-administered therapies.

References
1. Department of Health. Health Technical Memorandum 07-01: Safe Management of Healthcare Waste. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063274.
2. Ribeiro-Crespel V, et al. Hosp Pharm Eur 2009;46:63-64.
3. Weir PJ, et al. Hosp Pharm Eur 2009;47:58-60.
4. Leonard D. Hosp Pharm Eur 2009;46:66-68.
5. Leigh JP, et al. Am J Infect Control 2008;36:414-420.
6. Blenkharn JI, et al. Ann Occup Hyg 2008;52:281-286.
7. Hanan ZI. Infect Control Hosp Epidemiol 1990;11(10 Suppl):566-568.
8. Blenkharn JI. Brit J Comm Nurs 2009;14:38-39.



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