VOL: 97, ISSUE: 40, PAGE NO: 51
ELAINE SWAN, RN, SCM, BN, is advanced nurse practitioner (colorectal), Walsall Hospitals NHS TrustELAINE SWAN, RN, SCM, BN, is advanced nurse practitioner (colorectal), Walsall Hospitals NHS Trust
However well adjusted an ostomate becomes, disposal of equipment can lead to social inconvenience, embarrassment and even disgust (Harlow, 1988). To achieve rehabilitation and a return to a full and undiminished role in society the nurse must be aware of the effects soiled equipment disposal can have on patients.
The Environmental Protection Act (1990) made law a 'duty of care' to ensure safe disposal of controlled waste, including clinical waste, making those who produce, carry, keep and dispose of waste liable under criminal law (Box 1). Increased day surgery and early discharge of patients has led to increased clinical waste in the community.
Nurses need to provide guidance so that waste is dealt with safely and effectively. Risk assessment is the process of identifying hazards to patients, family and health care workers associated with health care waste and provides objectivity in deciding the degree of risk and appropriate control measures. All risk assessments should be reviewed regularly and as an integral part of the care plan. The process of assessing risk should always consider the patient's condition and identify factors likely to suggest if any waste generated might be infected. With this exception any other waste can be disposed of through the regular household waste collection system.
RCN guidelines (RCN, 1994) recommend that ostomy bags should be emptied into the toilet, then wrapped in newspaper or placed in a disposal bag designed for the purpose and placed in the dustbin. Many ostomates cannot manage this task for either physical or psychological reasons. The emptying of a pouch can be an arduous, offensive experience.
Literature relating to the disposal of stoma bags is limited, but all showed that ostomates raise disposal as a problem area (Kelly and Henry, 1992; Wade, 1989; Harlow, 1988; White, 1997).
Where waste is non-infectious it falls outside the definition of clinical waste (HSC Health Services Advisory Committee, 1999). However, some household waste may be considered of an offensive nature. Adequate steps should be taken for proper handling and disposal to protect those handling waste. The waste should be properly wrapped and free from excess fluid.
Although many local authorities now provide collection services, many ostomates prefer not to use them, feeling that the yellow bag collection service calling at their home only serves to highlight their disability.
Kelly and Henry (1992) observed that disposal of used equipment was one of the most frequently reported difficulties of ostomates.
Wade (1989) also found disposal for ostomates to be a problem away from the home which often prevented them from travel. Those who did travel were anxious beforehand and dreaded having to change a bag in somebody else's home. Some pouch manufacturers have now developed biodegradable appliances that can be flushed down the toilet. This has proved a useful option to some ostomates but is only available to those with colostomies at present.
Five environmental health officers (EHOs), local to our trust, were interviewed by telephone using semistructured interview schedules to collect data concerning demographic and background information on disposal methods of soiled equipment. Four stoma care nurses were systematically sampled from a directory of stoma care nurses in the same corresponding areas to the EHOs and invited to take part in the research. Stoma care nurses for six other areas - rural and urban - throughout the UK were systematically sampled. District nurses from the 10 areas were identified and all were sent a questionnaire containing 15 questions concerning the type of disposal services available and recommendations for disposal by health professionals. They were also asked about the ostomate's choice and problems with disposal of appliances.
The response rate was good, with 75% of respondents returning questionnaires - three district nurses and two stoma care nurses did not reply and one EHO declined to be interviewed. The results highlighted several important issues. All health care professional groups gave differing information to ostomates regarding stoma bag disposal.
Four areas within close proximity of each other offered different methods of disposal and interpretations of the Environmental Protection Act (1990). Research findings emphasise the need for clarification on the issue of disposal of stoma bags in the community. Results supported the literature in that waste disposal is a problematic and confusing area for ostomates, but it was found that health care professionals are not fully aware of this.
Most areas had either household waste service or yellow bag collection service, or both, available for soiled equipment disposal. Although services were available in an area they were not always recommended: 82% of stoma care nurses recommended household waste but 100% of stoma care nurses also advised to empty contents of the pouch before disposal.
All nurse respondents advised emptying the pouch before disposal in household waste. Seventy-nine per cent of responses stated that recommendations were advised by local environmental officers or because of legal requirements.
EHOs' recommendations for the disposal of stoma bags varied from area to area. Urban areas tended to recommend yellow bag collection as the preferred method of disposal, and rural areas recommended household waste collection. One of the urban areas did recommend household waste but in this area all waste was incinerated. The majority, 62%, of EHO responses stated that the emptying of contents of the pouch into the toilet and wrapping in newspaper or a plastic bag before disposal in household waste was recommended as the method of disposal; 29% of responses chose to empty the contents of the pouch into the toilet and cleanse in the flush before disposing of it in household waste. The majority of health care professionals are advising clients of the need to empty or cleanse the bag before disposal in household waste.
EHOs were shown to have varying interpretations of the legal requirements:
- One area gave mainly uniform advice by all respondents. Here all waste is or is not clinical waste and dealt with as such. EHOs commented that no problems were experienced with disposal methods advised, all household waste was incinerated, stoma bags were not classed as yellow bag waste - only infected dressings and continence pads were;
- Another area was also uniform in the advice given: only large quantities of continence pads/stoma bags were considered clinical waste and collected via the yellow bag collection system with infected waste. One EHO stated that both yellow bag collection and household waste was available and that 'colostomy bags are classed as low-risk waste and could be disposed of in the household waste by emptying and double wrapping if possible.' If large quantities of this waste was produced then yellow bag collection was advised, otherwise it was unnecessary and costly to collect smaller amounts;
- In two other areas EHOs gave differing advice, leading to confusion among health care professionals and clients. The officer in one area commented that 'stoma bags should be classed as clinical waste and not put into household waste'. Seventy-five per cent of all respondents from this area recommended yellow bag collection and 25% household waste;
- Two EHOs from different sections were interviewed in another area: one recommended yellow bag collection and commented that household waste was not recommended for disposal of stoma bags, although it may be classed as low grade clinical waste, the other recommended household waste.
Fifty per cent of respondents recommended yellow bag service and 50% household waste. The stoma care nurse in one area stated that although emptying the contents of the pouch into the toilet and cleansing in the flush was the disposal method recommended, 'people do not comply because they find cutting and emptying the bag messy, tending to just wrap bag and contents in a plastic bag or newspaper, which is easier'.
Clients receiving hospital treatment in one area and then returning home to another area may be given differing advice unless health care professionals are aware of local policies' discrepancies, which could hinder rehabilitation (Kelly and Henry, 1992). Fifty-nine per cent of health care professionals did not offer a choice of disposal method and none of the EHOs offered choice.
Rightly, EHOs were concerned with health and safety issues - waste transportation and the safety of workers at the final destination. The fears and worries of ostomates were unknown to the EHOs; 86% of stoma care and district nurses interviewed stated that in their experience ostomates had not experienced problems with disposal. And 100% of respondents stated that the same method was recommended when away from home, which may be difficult if local disposal methods varied.
Ninety-five per cent of respondents stated that ostomates usually complied with advice given, but perhaps it would have been interesting to gather this information from ostomates a year or so after surgery, when health care professionals were no longer in attendance.
Wade (1988) explained that, to improve client care, a better understanding from the client perspective was necessary. Are health care professionals viewing waste disposal on a far too superficial level and making assumptions about client capabilities as far as waste is concerned? Should we be educating clients about the legal, social and environmental issues, empowering them to take control of their lives?
Many people react with shock and disgust when told they require a stoma, and this surgery has a profound effect on the mind as well as the body. A sensitive and uniform waste disposal policy can support best practice across all health care professional groups so that consistent advice can be given to all ostomates.
This study demonstrates the need for clear guidelines for disposal of stoma bags in the community, taking into consideration the psychological issues particularly relevant to this client group. All professionals groups should ensure that advice given is consistent to avoid confusion.
Further consideration should also be given by health care professionals to disposal when travelling and to units such as those available for nappies and sanitary towels being introduced for disposal of stoma bags.
Nurses should give advice to clients that is research-based and sensitive to their needs and work with local EHOs in promoting best practice and consistent information to ostomates.