Current Status of Home Medical Care Waste Collection by Nurses in Japan

ABSTRACT

A questionnaire survey was conducted to determine the current status of home medical care (HMC) waste collection by nurses for individual items and whether the collection rate differs with city size. The questionnaire was mailed to 1,022 nursing offices, of which 645 offices provided valid responses. Offices were classified into three groups according to the local population size. Responses indicated that used syringes and needles, except for pen-type self-injection needles, were collected by >50% of HMC nurses. On the other hand, enteral nutrients, nutritional adjustment diet vessels, feeding tubes, portable injectors, ventilator masks, endotracheal suction catheters, tracheal cannulas, continuous ambulatory peritoneal dialysis (CAPD) bags, and urinary catheters and bags had a low collection rate in comparison with syringes or needles. The collection percentage of used syringes, needles, and infusion needles (p < 0.05) and that for infusion bags, tubes, and catheters (p < 0.001) differed among the three population groups. Although municipalities are responsible for collect all HMC waste, sharp or infectious items should be collected by HMC doctors or nurses. On the contrary, nonhazardous HMC waste should be collected by municipalities.

Implications: This paper illustrates the status of waste collection of individual home medical care (HMC) items by HMC nurses. Infectious waste, such as needles and syringes, is collected by nurses. The collection rate of infectious waste by nurses in large cities was low compared with that in small cities. Although municipalities are responsible for collecting all HMC waste, sharp or infectious items should be collected by HMC doctors or nurses, whereas nonhazardous HMC waste should be collected by the municipalities.

Introduction

Home medical care (HMC) services have become more prominent and widespread in Japan over recent years, with 4655 registered HMC offices currently in operation in Japan (National Association for Home-Visit Nursing Care, 2015). Domestic medical waste is a constant concern and growing problem in HMC. The Japanese Waste Disposal and Public Cleansing Law classifies waste materials as industrial or general waste (Japan Ministry of the Environment, 2001). Industrial waste results from business activities, whereas general waste refers to any other waste (Miyazaki and Une, 2005). Infectious waste is not only from hospitals and clinics but also from households. The disposal of infectious waste, such as blood from hospitals or clinics, is controlled in a way similar to that of industrial waste. Syringes or injection needles are designated as “specially controlled industrial waste,” whereas discarded absorbent cotton, cotton balls, bandages, and cotton gauze originating from hospitals and clinics are designated as “specially controlled general waste.” On the other hand, all waste items discharged from households are classified as “general waste” (Japan Ministry of the Environment, 2008). In particular, used syringes and needles originating from hospitals and households are designated as “specially controlled industrial waste” and “general waste,” respectively (Figure 1).

Figure 1. Classification of infectious waste under Japanese waste management law. All infectious waste discharged from households is classified as “general waste.” In particular, used syringes and needles originating from hospitals and households are designated as “specially controlled industrial waste” and “general waste,” respectively.

Due to increasing concerns over the amount of waste collection associated with HMC, the Japanese government demanded that HMC waste be collected by the municipalities in 2005 (Japan Ministry of the Environment, 2005a). Thus, municipalities are now responsible for the collection of HMC waste. However, some municipalities do not collect some or all HMC waste due to fear of infection or the presence of sharp objects (Japan Ministry of the Environment, 2005b; Miyazaki et al., 2007; Harada, 2007; Harada, 2011). On the other hand, some large municipalities have been collecting HMC waste and have developed guidelines for HMC waste handling (City of Nagoya Environmental Affairs Bureau, 2015; City of Yokohama Resources and Waste Recycling Bureau, 2015). HMC waste collection started in the larger municipalities, and it was assumed that the small- and medium-sized municipalities would also begin processing this type of waste. However, thus far, there has been no research as to whether these municipalities are complying with these requirements. An additional concern is the types of items included in HMC waste, as some sharp objects may be contaminated with infectious agents, thereby introducing significant possible risk factors for municipalities and their workers. Studies on HMC sharp waste in the United States (Gold and Schumann, 2007; Chalupka et al., 2008) and HMC waste infection control in the United Kingdom (Cole, 2007; Cutter and Gammon, 2007) have generally recommended that sharp or infectious items be disposed of by doctors or nurses, and it has been particularly emphasized that needles and infectious materials should not be handled by nonmedical personnel. Further studies have also recommended that professional HMC education on the proper handling of HMC waste be given to all patients (Bobolia, 2006; Gold and Schumann, 2007; Ikeda, 2014). However, regardless of these concerns and recommendations, there has been little research on HMC waste collection, and the available research has only included small samples (Hirai et al., 2001; Yano et al., 2002; Sugihara et al., 2009) and a low response rate (Sugihara et al., 2009). Unfortunately, none of these small studies have examined the collection and disposal of separate HMC waste items, such as needles and infectious items. Therefore, the purpose of the current study was to investigate the current status of HMC waste collection by nurses for individual items and whether the waste collection rates differ with city size.

Materials and methods

The present study was conducted as a follow-up of a previous prospective cohort study. A total of 1,283 nurses representing offices participated in the 2009 baseline study (Ikeda, 2014). The follow-up questionnaire survey was mailed to the same 1283 offices, of which 261 surveys remained undelivered and 1022 were delivered. A representative nurse for each office responded. Of those delivered, 677 (66.2%) nurses replied positively for the follow-up study, 27 offices had closed down, and 5 offices had been integrated with other offices. An analysis of the remaining 645 offices was performed. Offices were first classified into three groups by population size: Offices in municipalities with <50,000 people were classified as small-sized city offices, those with ≥500,000 people were classified as large-sized city offices, and populations that fell between these two were classified as medium-sized city offices. Statistical analyses were conducted using SPSS (Statistical Package for Social Sciences) statistical software (Ver. 21, IBM Corp.). For comparisons among the three population groups, analysis of variance (ANOVA) was performed and if significant, pairwise comparisons were performed. Scheffé’s multiple comparison procedure was applied to adjust the level of statistical significance to 5% when three groups were compared. Continuous parameters with normal distribution were analyzed by Student’s t-test. Binary variables were analyzed using the chi-squared test. A two-tailed test was used for all statistical analyses. In all cases, a p value of 0.05 indicated statistical significance.

Results

Basic characteristics of the subjects

In all, analyses of 645 offices were performed. Offices were classified according to the population of each office address (Japan Ministry of Internal Affairs and Communications Statistics Bureau, 2010) (Table 1). In general, small-sized cities had few nurses, with few home visits conducted per month (Table 1). However, these differences were not statistically significant. The representativeness of the sample was compared with the national statistics (Japan Ministry of Health, Labour and Welfare, 2014). There were no differences in the numbers of nurses’ offices and numbers of visits per month.

Table 1. Basic nursing office characteristics.

	Small-sized city (n = 211)	Medium-sized city (n = 265)	Large-sized city (n = 169)
Opening year	1998.2 ± 0.7	1998.7 ± 0.3	1999.6 ± 0.4
Full-time nurses	4.15 ± 0.17	4.70 ± 0.15	4.72 ± 0.19
Part-time nurses	3.06 ± 0.22	3.32 ± 0.21	3.84 ± 0.36
Number of home visits per month	422.5 ± 21.8	454.7 ± 19.6	487.9 ± 23.2

Note. Values are means ± standard error.

Waste collection status

More than 50% of the HMC nurses collected used syringes and needles, except for the pen-type self-injection needles (Table 2). On the other hand, the collection rate of enteral nutrients, nutritional adjustment diet vessels, feeding tubes, portable injectors, ventilator masks, endotracheal suction catheters, tracheal cannulae, continuous ambulatory peritoneal dialysis (CAPD) bags, and urinary catheters and bags was small compared with that for other HMC items (Table 2). More HMC nurses in small-sized cities collected HMC waste from the homes of patients than those in medium- or large-sized cities (Table 2). The collection percentage of used syringes, needles, and infusion needles (p < 0.05) and that of infusion bags, tubes, and catheters (p < 0.001) differed among the three population groups (Table 2).

Table 2. Percentages of home medical care (HMC) waste collections for individual items by HMC nurses.

HMC items	Small-sized city (n = 211)	Middle-sized city (n = 265)	Large-sized city (n = 169)
Used syringes (blood adhered)*	72.1	64.1	57.4
Used syringes (drug only)*	68.0	60.5	53.8
Needle*	74.6	67.2	59.2
Infusion needle*	73.8	66.1	58.0
Pen-type self-injection needle	28.7	29.1	28.4
Infusion bag, tube, catheter***	68.0	53.4	40.8
Infusion pump	23.8	21.8	16.0
Central venous catheter	29.5	28.2	23.7
Nasal tube, gastric fistula catheter	26.2	26.6	23.7
Enteral nutrients, nutritional adjustment diet vessel, feeding tube	15.6	14.4	14.2
Portable injector (for morphine injection)	13.9	17.2	16.0
Ventilator mask	4.9	11.0	11.8
Endotracheal suction catheter	18.0	19.2	17.2
Tracheal cannula	14.8	11.9	13.0
Continuous ambulatory peritoneal dialysis (CAPD) bag	4.9	5.6	4.7
Urinary catheter, bag	35.2	31.4	26.6

Note. Significant difference by chi-squared test among the different-sized cities: *p < 0.05, ***p < 0.001.

Discussion

This study demonstrated the current status of HMC waste collection by item and population based on the responses to questionnaires given to nurses.

In the current situation, hazardous HMC items, such as syringes or needles, were collected by nurses. This is a responsible protocol, as these items can easily accidently pierce the skin during handling, and the risk of accidental infection can be high. Previous studies on sharp HMC waste items in the United States (Chalupka et al., 2008; Gold and Schumann, 2007) and the control of infection (Cole, 2007; Cutter and Gammon, 2007) and legislation in the United Kingdom (Blenkharn, 2008; Griffith and Tengnah, 2006) have recommended that sharp or infectious items should be collected by HMC doctors or HMC nurses. According to the Japanese Waste Disposal and Public Cleansing Law, infectious waste discharged from households is categorized as general waste (Japan Ministry of the Environment, 2001). If we strictly adhere to the law, the storage of waste in the houses of patients until the general waste collection day presents a problem (Ikeda, 2014). It is, therefore, considered appropriate that health care workers preferably collect these infectious items and sharp objects. In addition, in its guidelines for HMC waste, the Japan Medical Association states that health care workers should be suitably equipped to collect sharp or infectious materials (Japan Medical Association, 2008). Depending on the population size, these waste syringes or needles were collected by HMC nurses (Table 2, p < 0.05). Three reasons are considered for this outcome. First, the numbers of visits by a nurse to the homes of patients may differ between urban and rural areas. In Table 1, although a statistically significant difference was not found, the number of visits per month by offices in large cities was greater than for small cities. Whether these increased visits per month result in a decreased collection rate of infectious waste remains unknown, and further studies are required to understand this. Second, large cities may be promoting the collection of infectious waste by doctors or municipalities to a greater extent than small cities are. In fact, some large municipalities have been collecting HMC waste and have developed guidelines for correct handling of HMC waste (City of Nagoya Environmental Affairs Bureau, 2015; City of Yokohama Resources and Waste Recycling Bureau, 2015). HMC waste collection started in the larger municipalities, and it was assumed that the small- and medium-sized municipalities would also begin processing this type of waste. However, the present study has not obtained data on waste collection from doctors or municipalities, and the collection of this is an issue for future research. Third, some home patients do not want to treat HMC waste as general waste because of their underlying fears of revealing their disease to the public (Yano et al., 2002). This is particularly true in the case in small-sized cities where patients in a neighborhood know each other; nevertheless, further studies are required to understand this factor.

A small percentage of the pen-type self-injection needles were collected by HMC nurses. These items are used for the self-injection of insulin and incorporate a safety mechanism for disposal. Moreover, a small percentage of nonhazardous items, such as nutrients, tubes, bags, and masks, was also collected by HMC nurses. A reason for this may be that municipalities collect these nonhazardous wastes. In many cases, municipalities in metropolitan areas collect home medical waste (City of Nagoya Environmental Affairs Bureau, 2015; City of Yokohama Resources and Waste Recycling Bureau, 2015). Information for small municipalities is not yet available; however, these nonhazardous items may be collected by small municipalities. The present study did not clearly determine whether large cities collected HMC waste to a greater extent than small cities, as these data were not available from municipalities.

The present study had several advantages over previous studies with respect to study design. First, data were collected from a representative sample of HMC nursing offices. In the present study, 645 nursing offices were included, of which 13.9% were registered by the National Association for Home-Visit Nursing Care (2015). Despite conducting a nationwide survey, the response rate for this follow-up study was 66.2%. However, the limitations of the current study must not be overlooked. First, because the subjects surveyed were only home-visit nurses, no conclusions can be drawn regarding any other organizations and occupations involved with HMC waste collection, such as municipalities, doctors, and medical institutions. Second, questionnaires were answered by nurses; therefore, the conclusions of the present study may not be applicable to home visiting doctors. These additional questions and considerations, among others, should be the focus of future studies.

Conclusions

Domestic medical waste is a constant concern and growing problem associated with HMC services. Infectious waste items, such as needles and syringes, have been collected by nurses. The collection rates of infectious waste by nurses in large cities were low compared with those in small cities. Although municipalities are responsible for the collection of all HMC waste, sharp or infectious items should be collected by HMC doctors or nurses, whereas nonhazardous HMC waste should be collected by municipalities.

Funding

This study was supported by the Yuumi Memorial Foundation for Home Health Care (2014–2015).

Additional information

Funding

This study was supported by the Yuumi Memorial Foundation for Home Health Care (2014–2015).

Notes on contributors

Yukihiro Ikeda

Yukihiro Ikeda, Lecturer, Center for Occupational Safety and Health Management, Kindai University Hospital.