REPORT ON THE FIRST YEAR OF THE PRESCRIBED SHARPS SERVICE PROVIDED BY NHS FIFE COMMUNITY PHARMACIES. Andrew Thornley Senior Community Services Pharmacy Technician NHS Fife Community Services June 2016 NHS Fife Pharmacy - Community Services Page 1 of 8 Review 2017
1. Introduction Community pharmacies provide pharmaceutical services to the population of Fife. As well as prescriptions, they provide additional services which include Minor Ailments, Chronic Medication Service and Smoking Cessation. Increasingly there has been a requirement to remove associated waste produced by patients at home when treating various medical conditions, commonly known as `Sharps Waste. Sharps waste falls within the definition of controlled waste in terms of the Environmental Protection Act 1990 and is required to be disposed of in accordance with requirements and guidance from the following documents. Scottish Environment Protection Agency, Health Technical Memorandum 07-01 (HTM 07-01) - Safe Management of Healthcare Waste. NHS Fife General Policy Document - Waste Management GP/W1, Nov 2013 NHS Fife Clinical Pharmacy Standard Operating Procedure, Management of Prescribed Sharps in NHS Fife, August 2015. Uncontrolled sharps waste can pose a health risk to other people by penetrating the skin with an infected sharp; in this way it is possible for the waste product to spread blood-borne pathogens. Healthcare professionals expose themselves to the risk of infection when handling sharps waste (needle stick injury). The general public can also be at direct risk to injuries from sharps waste if hazardous materials are not separated from standard household waste or are discarded irresponsibly in public places or in unsuitable containers. In response to increased incidents where sharps waste was disposed of in household waste or found in public places, NHS Fife Pharmacy Services in collaboration with all the Fife Community Pharmacies and NHS Fife Transport initiated a Sharps Waste service in January 2015. This service provided both the safe removal of full waste sharps containers from the community pharmacies and the replenishment of sharps containers for both pharmacy and patient use. This audit was carried out to assess the first year of this new service. A questionnaire was completed by a Community Services Pharmacy Technician in each pharmacy. NHS Fife Pharmacy - Community Services Page 2 of 8 Review 2017
2. Method Between November 2015 and February 2016, all 87 Community Pharmacies in Fife were visited and questions asked to staff by a member of the Pharmacy Community Services Technician Team. In order to gain as much information about training and service provided, questionnaires were asked to different professions within the community pharmacies, not just the counter staff. The results of all the visits were then compiled and analysis conducted. 3. Results The results were compiled and percentage compliance values calculated for each question. A compliance table for all questions, showing numbers and percentages is provided in appendix 1. A compliance graph of the results showing the percentages and highlighting questions were compliance was found below 95% is provided at appendix 2. 71 persons questioned had the opinion that training supplied to them was adequate or above; however 15 staff stated more training would be required or too little was provided (Q4). Eleven staff stated they had not received any training (Q3). One pharmacy did not provide the service as staff that received the training did not pass the information onto other staff members before leaving. All questions were amended to reflect only 86 pharmacy visits (Q1). All 86 pharmacies used the current NHS Fife SOP or had an equivalent SOP produced by the company group (e.g. Boots). All SOPs were shown when requested (Q2). All community pharmacies were issued with necessary documentation after the initial training session provided (Q7). 81 pharmacies had clear procedures for dealing with needle stick injuries, with posters and information readily displayed (Q8). All pharmacies have been offered Hepatitis B vaccinations for staff. In many pharmacies staff had already been vaccinated (Q9). 82 staff could readily provide information of contact details for supplies of extra containers and queries (Q5) Most people questioned could identify the main types of containers used for the sharps service (Q 10). 41 pharmacies did not use the temporary lid closures on larger containers, three locations used adapted cupboards for posting patients sharps containers which did not allow for the lid closure to be used (Q14). NHS Fife Pharmacy - Community Services Page 3 of 8 Review 2017
64 pharmacies did not mark opening and closing date on their large containers which is a requirement of the Prescribed Sharps SOP and road regulations from the SEPA memorandum (HTM 07-01)(Q 16). Sharps waste storage areas for both empty and full containers were located in adequate areas within all pharmacies, away from medicines and medicinal food products (Q17). 83 pharmacies actively offered the service to both current and new patients. Three pharmacies only offered the service to existing customers (Q8). 85 staff, when questioned could provide an adequate explanation of the correct service provided to patients requiring new sharps containers to be supplied or used containers to be disposed of (Q9). All pharmacies accepted correctly sealed sharps containers, even if it was a different container than they supplied (Q11). 51 pharmacies enabled patients to place their used sharps containers into the larger container themselves; in 35 pharmacies pharmacy staff took the used container from the patient at the counter and placed them in the larger containers themselves (Q12). Five pharmacies had received non-compliant containers (e.g. glass jars and plastic tubs) from patients containing used sharps, the staff then repackaged the used sharps into approved containers themselves. Staff were reminded that the patient should be given empty sharps containers and requested to conduct this themselves, as laid out in the Prescribed Sharps SOP (Q13). All pharmacies have washing facilities available; however only 82 staff stated that they washed hands after handling used sharps containers (Q15). 4. Discussion Overall a high rate of compliance of community pharmacies and their staff was found. Only six of the questions analysed had a result of less than 95% compliance. These six reduced compliance findings are discussed below. Whilst training was provided to each pharmacy when the system was initiated, some pharmacy staff did not pass on the information to other staff members, resulting in 11 of the people interviewed stating no training had been received; this is also backed up by answers to question 4, showing that 15 persons would request more training if it were to be provided. NHS Fife Pharmacy - Community Services Page 4 of 8 Review 2017
An issue with many of the pharmacies has been with the pickup / delivery schedule which is scheduled to occur on a five week rotation. This has been very changeable in the initial year with driver schedules being changed without informing the pharmacies of the change. Further work has been done with NHS Fife Transport to improve this process, ensuring that information is communicated to the pharmacies when delays occur and an email is sent to all pharmacies in advance of their uplift day. Many pharmacy staff are taking patient's used sharps containers and placing them into the larger container themselves, rather than bringing the large container to the patient as demonstrated during the initial training provided. In most pharmacies the larger boxes are placed at the rear of the pharmacy and staff have little time to move these boxes, or allow the patient to walk through the pharmacy to place the containers in themselves. In those pharmacies where staff handle the boxes to transport them to the larger containers, the managers are relying on staff having good hand washing procedures after collecting containers from the patients in order to maintain infection control. Only a few pharmacies have designated areas at the front of the pharmacy countertop, where patients can place their used containers into the larger bins. Nearly half of pharmacies are not using the temporary closures in the larger bins or placing the top closure lid on the container before it is started. In a few cases lids are not used as the bins fit into special cupboards, allowing the smaller containers to be posted into them by the patients. This presents a problem if these boxes then spill, allowing contents to empty onto the floor. This has been discussed with the pharmacy staff during the visits. 64 pharmacies were not marking containers with start date and closure dates as instructed in the NHS Prescribed Sharps SOP. This process is compulsary to ensure traceability of the containers, this is part of the road transport regulations and cannot be omitted. 5. Recommendations Pharmacy Services will put in place an action plan highlighting those pharmacies where compliance was lower than expected and will provide further education and training in the service. Pharmacy Services will review the NHS Prescribed Sharps SOP to emphasise and reinforce the marking of containers with start and closure dates which is a requirement of road transport regulations. NHS Fife Pharmacy - Community Services Page 5 of 8 Review 2017
Pharmacy Services and Transport will work to improve communication to community pharmacies regarding uplift and delivery schedule dates. In accordance with the Service Level Agreement, Pharmacy Services will provide an annual education event for all community pharmacies to ensure they understand their responsibilities in providing the service and that all staff have the opportunity for appropriate educated. Community Pharmacies are reminded to ensure that any patient whom produces sharps as part of their healthcare is fully informed of the Sharps Service and is provided with appropriate sharps containers. 6. CONCLUSION This report identified gaps in the processes for dealing with prescribed sharps containers in community pharmacies within Fife. Further work will be required to provide training and advice to pharmacy staff to improve their risk awareness when dealing with used sharps containers, preventing sharps injuries from handling non sealed containers from patients and potential spillages from non closed large containers. Improving traceability by marking opening and closing dates on containers will need to be instilled into pharmacy staff in line with road transport regulations. NHS Fife Pharmacy - Community Services Page 6 of 8 Review 2017
Appendix 1 SHARPS QUESTIONNAIRE FORM FOR NHS FIFE COMMUNITY PHARMACIES CONTAINING COMPLIANCE DATA AND PERCENTAGES 1 2 3 Standards Does this Pharmacy offer a full Sharps waste service? Do you follow the current NHS Fife SOP, or has the Pharmacy produced its own SOP? Have all relevant staff been trained to provide the service? 4 In your opinion, have staff had sufficient training Compliance Yes No Percentage Compliant 86 0 100% 86 0 100% 75 11 87% Too Little 2 (2%) More required 13 (15%) Do you know who to contact should extra sharps 5 containers be required or used sharps containers require to be collected. Do you know the pick-up/ delivery schedule for 6 your pharmacy. Has the pharmacy copies of the following documents, 7 SOP, Order forms, Safety sheets Do staff offer this service to new and existing 8 patients who use medicinal sharps. When dealing with sharps waste, can you explain 9 the service provided to the patient. Explain the Two types of Sharps waste containers 10 and their differing usage. Do you accept all correctly sealed medicinal 11 sharps containers Who puts the patient sharps boxes into the large 12 bin in your pharmacy? What action would the pharmacy take if a patient 13 brought sharps waste that wasn t in an authorised container? Are temporary closures used on the large sharps 14 bin in the pharmacy while still in use? Do staff wash hands after handling sharps 15 containers? Have the pharmacy sharps containers been 16 marked with opening and closing dates? Are used / full containers stored in an appropriate 17 location. Do you have a procedure for needle stick injuries 18 and are personnel aware of it. 19 Have the staff been offered Hep B vaccination. 82 4 (not required) 20 Are there any procedures with the provision of the service that could be improved? Adequate 69 (80%) 82 4 95% 61 25 70% 86 Nil 100% 83 3 96% 85 1 98% 85 1 98% 81 5 94% 51 35 59% 81 5 94% 48 38 55% 82 4 95% 22 64 25% 86 0 100% 81 5 94% 95% 84 4 97% Too much 2 (2%) Areas showing where percentage compliance at less than 90% NHS Fife Pharmacy - Community Services Page 7 of 8 Review 2017
Q1 Does this Pharmacy offer a full Sharps waste service? Q2 Do you follow the current NHS Fife SOP, or has the Pharmacy produced its Q3 Have all relevant staff been trained to provide the service? Q4 Have staff had sufficient training (opinion) Q5 Do you know who to contact should extra sharps containers be required or Q6 Do you know the pick-up/ delivery schedule for your pharmacy. Q7 Has the pharmacy copies of the following documents, SOP, Order Q8 Do staff offer this service to new and existing patients who use medicinal Q9 When dealing with sharps waste, can you explain the service provided to the Q10 Explain the Two types of Sharps waste containers and their differing Q11 Do you accept all correctly sealed medicinal sharps containers Q12 Who puts the patient sharps boxes into the large bin in your pharmacy? Q13 What action would the pharmacy take if a patient brought sharps waste Q14 Are temporary closures used on the large sharps bin in the pharmacy while Q15 Do staff wash hands after handling sharps containers? Q16 Have the pharmacy sharps containers been marked with opening Q17 Are used / full containers stored in an appropriate location. Q18 Do you have a procedure for needle stick injuries and are personnel aware Q19 Have the staff been offered Hep B vaccination. Q20 Are there any procedures with the provision of the service that could be Percentage Compliance Appendix 2 Graph of Compliance Results to Questions from NHS Fife Sharps Audit 2016, Highlighting Compliance at values below 95% Percentage Compliance to NHS Fife Sharps Audit 2016 Questions 100 90 80 70 60 50 40 30 20 10 0 NHS Fife Pharmacy - Community Services Page 8 of 8 Review 2017