Sharps outside the hospital

Most of this course has been set inside Northbridge Community Hospital, where sharps containers hang on the wall, safety devices come from central supply and Employee Health and Safety is a phone call away. But a large share of sharps injuries happen elsewhere: in clients' homes, in long-term care, in clinics and dental offices, in police cars and parks, in school washrooms and in the back of garbage trucks. The workers in these places often have less equipment, less training and no one nearby to help. This lesson covers how the same principles apply when the hospital's systems are not there.

Home care: the client's home is the workplace

Northbridge Home Health's 42 nurses, certified nursing assistants and therapists see about 310 clients, many of whom use needles every day for insulin, blood thinners, fertility treatment or other drugs. In the client's home, the worker does not control the lighting, the space, the pets or the other people in the room, and the sharps may be the client's own rather than ones the agency supplies.

Northbridge's home care procedure sets out a few rules that stay the same from house to house:

• Bring your own: every nurse carries a small sharps container in the visit bag, along with the safety-engineered devices for the procedures they will do, so they never depend on whatever the client has.
• Set up before you start: clear a flat, well-lit surface, put the container within arm's reach on the side of the dominant hand, and ask that children and pets be kept out of the room during the procedure.
• Dispose at the point of use: the used sharp goes straight into the container, with the safety feature activated, just as in the hospital. Nothing used is put down on a table, a bed or a cushion.
• Close and carry safely: the container is closed between visits and kept upright in a fixed holder in the car, not loose on the seat or in the trunk where it can tip.
• Never take a sharp out of a container, and never pour one container into another.

Clients who inject themselves are taught to use their own approved sharps container or, where local rules allow, a sturdy plastic bottle with a screw cap. Workers check the container on each visit. A container that is overfull, or a pile of used pen needles on the kitchen counter, is a hazard to the worker, the family and anyone who handles the household garbage.

Hazards that are hard to control in a home

Some risks in the community have no hospital equivalent, and they need planning before the visit rather than improvisation during it:

• Restless or confused clients. A client with dementia may pull away during an injection. The nurse plans the procedure for a calm time of day, explains each step, and asks a family member to help hold the arm when it is safe to do so.
• Sharps hidden in the home. Used needles may turn up in a bed, a sofa or the laundry, especially when the client is not managing their own disposal well. Workers never reach into a place they cannot see, such as under cushions or into a bag, without looking first.
• Pets. Dogs and cats can bump an arm, and cats in particular are drawn to anything that moves on a table.
• Poor light and cramped spaces. The nurse carries a headlamp or a small lamp and does not start a procedure until they can see clearly.
• Driving. A container that tips over in a car can open, so it is fixed in place, and used sharps are never carried in a pocket or loose in the bag.

Because home care staff often work alone, the exposure response is planned in advance. Each nurse carries a small exposure kit with gauze, a waterproof dressing, saline for eyes and the procedure card with the on-call number, so that the first aid steps in Lesson 9 can be done anywhere. After an exposure, the nurse calls the on-call line, finishes the visit only if it is safe and quick to do so, and goes to the nearest emergency department.

Long-term care

At Maple Court, the main sharps are insulin pens, blood glucose lancets and the occasional injection. The risks come from the residents and from routine rather than from complex procedures. A resident with dementia may grab a nurse's hand during a finger stick. A nurse doing a medication pass for 24 residents may be tempted to carry several used lancets to the cart rather than dispose of each one at the bedside.

Maple Court uses safety lancets that retract after one use, insulin pen needles with a safety shield at both ends, and small containers on each medication cart and in each resident's room where blood glucose tests are done. Lina Santos and the other certified nursing assistants do not handle needles, but they are trained to report any sharp they find and never to pick one up with their hands.

Clinics, dental offices and other health settings

Family practice clinics, walk-in clinics, dental offices, blood collection sites, pharmacies that give vaccines, physiotherapy clinics that use acupuncture needles, and veterinary clinics all handle sharps, often with a handful of staff and no occupational health department of their own. The rules for devices, containers, vaccination and post-exposure care apply to them as well, and the employer has to arrange in advance where a worker will be assessed after an exposure, usually the local emergency department or an occupational health clinic. Lesson 12 builds an exposure control plan for exactly this kind of small clinic.

Dental work has its own patterns. Many injuries come from burs, scalers, wires and syringes during cleanup of the tray, and dental offices often use a recapping device or a one-handed scoop for local anesthetic syringes, because the needle is used more than once on the same patient during a procedure. That is one of the few situations where recapping is allowed, and only with the device or the one-handed method.

Discarded needles in public places

Outside healthcare, the most common sharps hazard is a needle someone else threw away. Custodians in schools, malls and transit stations, parks and public works staff, sanitation and recycling workers, police officers, retail staff and hotel housekeepers all find discarded needles. The chance that one of these needles carries a virus that is still able to infect someone is lower than for a fresh needle in a hospital, because the viruses do not survive long when dried, and HIV in particular is fragile outside the body. But hepatitis B can survive on surfaces for at least a week, hepatitis C for days to weeks in some conditions, and any needlestick from an unknown needle is handled as an exposure.

Employers whose workers may find needles have duties under the Bloodborne Pathogens standard whenever contact with blood or sharps is reasonably anticipated in the job, which includes custodians and sanitation workers who regularly find needles. That means training, the right tools, a container, the offer of hepatitis B vaccine where appropriate, and post-exposure evaluation. Where contact is not reasonably anticipated, the General Duty Clause still applies. Many cities and counties provide public sharps disposal boxes and pickup services through their health departments or syringe services programs.

Picking up a discarded needle

Workers who may find needles carry or have quick access to a pickup kit: tongs or a long-handled grabber, a small rigid sharps container, puncture-resistant gloves and hand sanitizer. The steps are simple, and the most important ones are about what not to do: never use fingers, never recap, never break the needle off, and never put a hand into a place you cannot see, such as a trash bin, a gap between seat cushions, a bag or the back of a toilet tank. Waste bags are carried away from the body and never compressed with hands or feet.

Sanitation and recycling workers are often hurt by needles thrown into household garbage or, worse, into recycling, where sorters handle material by hand. That is one reason public programs ask people who inject at home to use a proper container and return it to a pharmacy or a drop-off point.

In the United States, the FDA recommends that people who use needles at home put them in an FDA-cleared sharps container right after use, or, if one is not available, a heavy-duty plastic household container with a tight lid, and follow their state and local rules for disposal. Some areas accept sealed household containers in the trash; others require drop-off at a pharmacy, a hospital or a collection site.

Police, corrections, security and first aid

Police officers, corrections officers, security guards and loss prevention staff can be stuck by needles during searches. The basic rules are the same as in a hospital: look before you reach, use tools, and dispose of sharps immediately. Officers are trained to ask a person before a search whether they have anything sharp on them, to pat down the outside of clothing slowly rather than reaching into pockets, to use a flashlight and mirror to look into hidden spaces in vehicles, and to put any needle found straight into a rigid container rather than an evidence bag. Bites and spitting during arrests are handled as possible exposures and assessed the same way.

Designated first aiders in workplaces such as factories, offices and schools may be exposed to blood when they help an injured coworker or student. Their first aid kits include gloves and a face shield or pocket mask for rescue breathing, and they follow the same rules for cleaning blood and disposing of anything sharp. A first aider who is exposed is assessed like any other worker.

Tattoo, piercing and personal service settings

Tattoo artists, body piercers, electrolysis and some aesthetic services use needles every day, outside any hospital. Public health rules for personal service settings require single-use needles, proper sharps containers, cleaning and disinfection, and records, and they are inspected by local public health. The workers in these businesses face the same hazards as nurses, and the same habits protect them: never recap, dispose at the point of use, and know where to go after an exposure.

Tracking where needles turn up

Joanne also sits on a city working group with public works, parks, the school board and the public health unit. The group pooled a year of reports of needles found by city and school staff, to decide where to put new public disposal boxes and where pickup crews should look first.

# Needles found and reported by city and school staff over one year
found = [
    ("riverside trail", 64), ("transit terminal", 51), ("central library", 23),
    ("downtown parking garage", 47), ("arena washrooms", 18), ("north park", 9),
    ("high school grounds", 6), ("recycling plant sort line", 14),
]
total = sum(n for _, n in found)
print(f"total needles reported: {total}")
running = 0
for place, n in sorted(found, key=lambda x: -x[1]):
    running += n
    share = round(100 * n / total)
    print(f"{place:26} {n:3}  ({share:2} in 100)  cumulative {round(100 * running / total):3} in 100")

total needles reported: 232
riverside trail             64  (28 in 100)  cumulative  28 in 100
transit terminal            51  (22 in 100)  cumulative  50 in 100
downtown parking garage     47  (20 in 100)  cumulative  70 in 100
central library             23  (10 in 100)  cumulative  80 in 100
arena washrooms             18  ( 8 in 100)  cumulative  88 in 100
recycling plant sort line   14  ( 6 in 100)  cumulative  94 in 100
north park                   9  ( 4 in 100)  cumulative  97 in 100
high school grounds          6  ( 3 in 100)  cumulative 100 in 100

Four places accounted for more than three quarters of the needles found. The group put disposal boxes at the trail head, in the transit terminal and in the parking garage stairwell, and agreed that crews would check those sites first each morning. The 14 needles found on the recycling sort line were a separate problem: they had all come through household recycling, so the city ran a campaign with pharmacies reminding residents never to put needles in household recycling.