An uncharted safety gap: inconsistent access to home sharps disposal in the UK

Summary

In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the difficulties people experience in disposing of needles and injection devices safely at home. Variation in services across the UK can lead individuals to dispose of sharps incorrectly, posing a risk to refuse workers and the wider public.

Content

Sharps injuries pose a significant global risk to staff and patient safety, and many of these injuries are caused by incorrect disposal. The Royal College of Nursing (RCN) estimates that there are 100,000 sharps injuries in healthcare in the UK every year,[1] and research by both the RCN and The European Biosafety Network highlights that the situation has worsened under the pressure of the Covid-19 pandemic.[2][3] There is also evidence that sharps injuries are underreported, meaning the number of incidents could be much higher.[2] The Safer Healthcare and Biosafety Network recently launched a working group on standardising injection technique in diabetes care to reduce the risk of needlestick injuries, which will include research to better understand the incidence and causes.

But a related area that has received little attention is the disposal of sharps at home, where a healthcare worker is not involved. There are many people who self-administer injectable medication and need to dispose of sharps at home, either on a long- or short-term basis. People with diabetes make up a large proportion of this group, but there are many others, including those self-administering warfarin, biologic drugs for autoimmune conditions, IVF and cancer treatments. And although “all HCPs, downstream workers and members of the public are at risk of sharps/needlestick injury,”[4] regulatory guidance outside of healthcare settings is minimal.

It makes sense that “safe disposal requires that… safe sharps disposal systems and processes be present and known to all persons at risk for sharps contact.”[5] But anecdotal evidence and lack of national policy on the issue suggest that this is not always the case for people in the UK who inject at home.

Although legislation requiring the safe disposal of sharps in healthcare and occupational settings was passed in 2013,[6] it does not cover sharps waste generated by individuals at home. Indeed, there is lack of clarity about who is responsible for making sure these sharps are disposed of safely. The NHS website states that, “If you have a medical condition… and use needles at home, your local council may be responsible for collecting your full sharps bin.” This statement demonstrates this lack of clarity for people who self-inject—that the local council ‘may’ help doesn’t speak of a clear, accessible safety process.

Improper sharps disposal is a global public health risk

This is a problem, because when needles and other sharps are not disposed of safely, they pose a considerable health risk to refuse workers, other household members and the general public. The TREND Diabetes ‘Correct Injection Technique in Diabetes Care Best Practice Guideline’, widely used by healthcare workers in the UK, states that “sharp medical devices present a potential risk for both injury and transmission of disease [such as] hepatitis and HIV.”[4] Sharps injuries can also have a significant psychological impact on individuals who experience them.

A 2021 study into unsafe sharps disposal around the world found that “a substantial number of patients with diabetes mellitus improperly discard their sharps” and described the situation as an “emerging global crisis and significant public health risk”.[7] There have been a number of other studies in the last five years into the situation with household disposal in multiple countries around the world including the US,[8] Ghana,[9][10] India [11] and Sri Lanka,[12] but no study of this kind has been conducted in the UK in the last decade. The most recent study that examined the UK situation was a global survey of people with type 1 diabetes carried out in 2009, which found that 21% of people with diabetes in the UK and Ireland were disposing of sharps directly into their household rubbish,[13] but we do not have a clear picture of the current extent of this problem.

The impact of improper sharps disposal is also difficult to assess. Like in the healthcare sector, there are very specific criteria for reporting needlestick injuries (NSIs) within waste disposal services. This means that the true number of sharps injuries as a result of improperly discarded domestic sharps in the UK is nearly impossible to quantify. However, we can look at the picture in the US, where recent research by The Environmental Research & Education Foundation into NSIs at municipal recycling facilities estimated that between 781 and 1,484 NSIs occur each year at recycling facilities.[14]

Home sharps disposal - the UK picture

Services and advice about safe sharps disposal vary geographically, and uncertainty about the process contributes to some people throwing their medical sharps in the general household waste, sometimes with no protective container at all. To get an idea of experiences in different areas, I asked social media contacts with type 1 diabetes in the UK about how they dispose of their sharps and the response was, as expected, mixed.[15]

The NHS website points to local councils as having responsibility, but a quick look at the provision offered by different local authorities in London demonstrates a varied picture. Some councils provide free pick up services, while Hackney council charges residents for the service. Some councils require a referral from a healthcare professional and some require individuals to drop sharps off at a designated location themselves.

Looking across the UK, evidence from patients suggests even wider variations in provision. Some areas of Scotland have no provision for sharps disposal at all, and one Twitter user in Scotland reported being asked by their diabetes specialist nurse to put their sharps in an empty detergent bottle before putting them in the normal household waste.[15] In the absence of a local clinical waste disposal service, this approach does offer some protection from injury, but it is clearly far from ideal. The TREND Guideline advises that, “Under no circumstance should sharps material be disposed of into the public refuse or rubbish system,”[4] indicating a mismatch between best practice recommendations and local policy.

There are also stark differences in how local councils present information. Some provide clear and thorough guidance on the process and how to access the service. For example, the Enfield Council website includes details of areas served and waste items covered, and an online form. But this is not the same everywhere, and one Twitter user described the information on their council website as “a horror show.”

Healthcare workers can also be unclear about home sharps disposal, particularly when someone is using them for short-term treatments. One patient told me, “I used needles at home for a short time whilst having my treatment and was given a bin to dispose of them in, but the nurses seemed unclear what I should do with it when full. They didn't give me any information on what to do with it, where to take it, or the dangers of just chucking it away.” This lack of knowledge demonstrates a process and knowledge gap that runs right the way through the healthcare system.

Tackling the problem of improper sharps disposal

So what needs to be done to improve the situation and reduce the safety risks associated with home use of needles and other sharps?

• Building an evidence base We need up-to-date research about the scale of improper home sharps disposal in the UK, and the prevalence and impact of injuries that occur as a result.
• National policy In response to this evidence, access to sharps disposal needs to be made consistent across the country, and national policy is needed to clarify the responsibility of local councils and NHS services. This would lead to greater clarity and easier access.
• Clear information on disposal processes If they are to fulfil their role in ensuring safe disposal, people who use sharps at home need clear, easy-to understand information. A national policy needs to be accompanied by clear information on who is providing the clinical waste services and where.
• Ongoing education on sharps disposal The TREND Guideline states that “safe disposal of sharps should be taught to people with diabetes who inject… from the beginning of the injection therapy initiation and reinforced thereafter.”[4] However, a 2018 US study found that people who had diabetes for more than 30 years had the lowest rate of correct sharps disposal,[16] suggesting that continued education is important.

Related reading

Injection technique and dual safety in diabetes care - a new SHBN working group to tackle safety risks
Needlestick injuries – making the point for safety
Sharps injuries and Covid (research by Ipsos MORI on behalf of European Biosafety Network)

References

1 Safer sharps. NHS Supply Chain. Accessed 5 January 2022
2 Pressures of pandemic and lack of training see 50% rise in sharps injuries. Royal College of Nursing, 21 May 2021
3 Sharps injuries and Covid. European Biosafety Network and Ipsos Mori, 24 July 2021
4 Hicks D, James J, Smith M. Correct injection technique in diabetes care: Best practice guideline, 2nd edition. Trend Diabetes. March 2021
5 Frid A, Kreugel G, Grassi G et al. New Insulin Delivery Recommendations. Mayo Clinic Proceedings. 1 September 2016
6 Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for employers and employees. Health and Safety Executive. March 2013
7 Thompson B, Cook C. Unsafe Sharps Disposal Among Insulin-Using Patients With Diabetes Mellitus: An Emerging Global Crisis. Journal of Diabetes Science and Technology. 1 December 2021
8 Montoya J, Thompson B, Boyle M et al. Patterns of Sharps Handling and Disposal Among Insulin-Using Patients With Diabetes Mellitus. Journal of Diabetes Science and Technology. 22 October 2019
9 Udofia E, Gulis G, Fobil J. Solid medical waste: a cross sectional study of household disposal practices and reported harm in Southern Ghana. BMC Public Health. 18 May 2017 
10 Egbenyah F, Udofia E, Ayivor J et al. Disposal habits and microbial load of solid medical waste in sub-district healthcare facilities and households in Yilo-Krobo municipality, Ghana. Plos One. 10 December 2021.
11 Moray K, Manjunath K, Shalini A et al. The insulin sharps disposal study: Evaluation of a structured patient education initiative in an urban community health centre in India. Journal of Family Medicine and Primary Care. 31 December 2020
12 Atukorala K, Wickramasinghe S, Sumanasekera R et al. Practices related to sharps disposal among diabetic patients in Sri Lanka. Asia Pacific Family Medicine. 7 December 2018
13 De Coninck C, Frid A, Gaspar R et al. Results and analysis of the 2008–2009 Insulin Injection Technique Questionnaire survey. Journal of Diabetes. 16 August 2010
14 Kantner D. Study Quantifies Needlestick Injury Rates for Materials Recovery Facility Workers. Waste 360. 10 September 2018
15 Twitter thread @LottyTizzard, 13 December 2021
16 Huang L, Katsnelson S, Yand J et al. Factors Contributing to Appropriate Sharps Disposal in the Community Among Patients With Diabetes. Diabetes Spectr. 2018:31:155-158