Journal of Public Health Advance Access originally published online on August 18, 2007
Journal of Public Health 2007 29(4):472-473; doi:10.1093/pubmed/fdm050
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Correspondence |
Hygiene and waste management in UK hospitals: are self-reported compliance scores always valid?
J. Ian Blenkharn, CBiol, CSci, FRIPH
18 South Road, Ealing, London W5 4RY, UK
E-mail: blenkharn{at}ianblenkharn.com
Evidence from audits of healthcare (clinical) waste management in UK hospitals performed in 20051 and 20062 had revealed generally poor standards of performance. In many hospitals, unlocked clinical waste carts were common, with many carts overflowing, with gaping lids and spilled items lying free at their base. Individual clinical waste sacks and sharps containers were frequently left on the floor, both within hospital buildings and in the hospital grounds, apparently due to a lack of sufficient waste carts and an inadequate frequency of collections for transfer of wastes to a secure central storage compound. Despite clear and unambiguous guidelines that mandate waste security, more than two-thirds of hospitals failed to lock individual waste carts. Bulk clinical waste carts and individual filled waste containers were stored in open and accessible locations without the provision of any security, with satellite storage of individual carts in corridors and stairwells, on access paths, in car parks and in locations that caused obstruction to doorways and to fire escape routes.
The current annual health check report published by the Healthcare Commission reports that 93% of NHS Trusts (n = 368) declared compliance for Core Standard C4e that specifies standards for the safe handling and disposal of waste.3 Overall, these data sit uncomfortably with the evidence of widespread deficiencies in clinical waste segregation, storage and security noted during successive audits. To examine possible discrepancies, 14 of the 16 hospitals included in the 2005 and 2006 clinical waste management audits, representing a service capacity in excess of 6500 acute hospital beds, were once more revisited during the first few days of July 2007. As previously, an assessment was made of the overall standards of clinical waste management. Observations were made during the working day only, and were restricted to public areas including hospital grounds, access roads, car parks, corridors and accessible service areas. At two hospitals, a move into new premises since the previous audit had facilitated substantial improvement in waste management standards. Waste management standards had improved in a further three hospitals, with better waste security, locked waste carts and better segregation of waste streams. Despite this, in 6 of 14 hospitals there was once again evidence of spilled wastes, of waste sacks and sharps bins left on the floor in public areas, of unlocked waste carts and of overfilled and overflowing waste carts, with waste carts stored in locations freely accessible to the public. Poor waste segregation remained common with cardboard boxes and black refuse sacks placed in clinical waste carts, whereas in one hospital several black sacks were mounted in yellow-lidded sack holders clearly marked for ‘clinical wastes’ and appropriately colour-coded for this hazardous waste stream. Contradicting the results of this and earlier audits, 13 of these 14 hospitals recorded compliance with the Healthcare Commission annual health check Core Standard C4e, that requires ‘the prevention, segregation, handling, transport and disposal of waste are properly managed so as to minimize the risks to the health and safety of staff, patients, the public and the safety of the environment’.
Some improvements have been noted in the current year, particularly in new build hospitals where design, layout and construction separate clean and dirty services to facilitate effective waste management. However, evidence of long-standing clinical waste management failures noted over successive years suggests widespread and serious failings that sit uneasily with the self-reported results summarized in the Healthcare Commission annual health check for 2006–7. This health check is intended to provide reassurance to the public about compliance with relevant safety and performance standards and with the hygiene code. All but 1 of the 14 Trusts had declared full compliance with the relevant C4e waste management standard. The Healthcare Commission seeks to confirm the accuracy of self-reporting through a series of random spot-checks and follow-up inspections, but this discrepancy suggests that the self-reporting process may owe more to a desire to achieve high ratings than it does to accuracy.
The Environment Agency and the Health and Safety Executive may deal robustly with deficiencies in clinical waste management occurring further down the disposal chain. However, many of the issues prompting regulatory action, including errors in segregation and the correct categorization of wastes, have their origins in the operational waste management standards of the waste producer. Further and widespread concerns regarding the standards of hospital hygiene and the prevention and control of hospital infections have placed greater attention on the standards of clinical waste management in hospitals. With the introduction of substantially tighter legislative controls and updated guidance, there are now considerable pressures on Trusts to improve performance in waste management.4 Despite this, the incorrect use of colour-coded waste containers, overflowing waste carts, inappropriate storage of waste carts, gross errors of segregation and failures to separate individual waste streams and gross deficiencies in waste security remain common. Earlier Healthcare Commission annual health checks referenced the Health Services Advisory Committee document ‘Safe disposal of clinical waste’ as the relevant standard.5 This has been updated for the 2006–7 health check to require Trusts to manage wastes properly in order to minimize the risks to patients, staff, the public and the environment in accordance with the provisions of the Environmental Protection Act 1990, the Controlled Waste Regulations 1992, and the Hazardous Waste Regulations 2005.6 The evolving legislative framework and operational standards demand rigorous segregation of wastes, the correct use of an unambiguous segregation scheme and containment of potentially hazardous clinical wastes, and secure storage of those wastes pending onward disposal. Notwithstanding, the fundamental requirement for safe, effective and secure management of potentially hazardous clinical wastes has remained unchanged. With evidence of multiple waste management deficiencies at hospitals that report full compliance with Core Standard C4e, the results of the annual health check process can falsely enhance the record of compliance in some UK hospitals, suggesting that self-reported compliance scores may not always be valid.
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- Blenkharn JI. Standards of clinical waste management in UK hospitals. J Hosp Infect (2006) 62:300–3.[CrossRef][Web of Science][Medline]
- Blenkharn JI. Standards of clinical waste management in hospitals—a second look. Pub Health (2007) 121:540–5.[CrossRef]
- Healthcare Commission. NHS trust declarations on standards for 2006/2007. http://www.healthcarecommission.org.uk/_db/_documents/Core_standards_2006_2007_declarations_briefing_note.pdf (13 July 2007, date last accessed).
- Estates and Facilities Division, Department of Health. Health Technical Memorandum 07-01: Safe Management of Healthcare Waste. In: ISBN 0-11-322766-3 (2006) London: The Stationery Office. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063274 (13 July 2007, date last accessed).
- Health Services Advisory Committee. Safe Disposal of Clinical Waste. In: ISBN: 0 7176 2492 7 (1999) Norwich: Her Majesty's Stationery Office.
- Healthcare Commission. The Annual Health Check in 2006/2007. Assessing and Rating the NHS. In: ISBN: 1-84562-114-X (2006) London.
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