Project targets medical waste left on food trays

Group effort eliminates problem

When the nutrition and food services employees at Park Nicollet Health Services in St. Louis Park, MN, complained that food trays were being returned with medical waste and sharps on them, the director of quality resources tackled the problem as a process improvement project. Six months later, the problem was virtually eliminated.

The problem had been simmering for a while, but in February, it was brought to the attention of Judy Wilson, RN, CPHQ, director of quality resources at Park Nicollet, an integrated care system that includes Methodist Hospital, Park Nicollet Clinic, Park Nicollet Foundation, and Park Nicollet Institute.

Park Nicollet Health has more than 6,800 employees, including more than 485 physicians on staff. Methodist Hospital is a 426-bed facility with 2,600 employees. Representatives from nutrition and food services came to Wilson and said staff were concerned about syringes and other potentially dangerous medical waste being left on the food trays when they were returned after meals.

"A lot of the items were oral syringes that patients had used and then just discarded on the trays, but some were syringes with needles that posed a potential hazard for needlesticks," Wilson says. "Even if the item had no needle and represented little risk of exposure, the staff in nutrition and food services couldn’t know which was which. So they ended up with a lot of anxiety [about] these items, no matter what they were," she adds.

Other waste items caused concern

Syringes weren’t the only items of concern. Nutrition and food services staff routinely found various other medical waste, such as gauze dressings and swabs. "This had bothered them for some time, and they finally came and asked for help," she says. "I was glad they did. I thought we could go through a root-cause analysis and solve this."

To get things started, Wilson invited nurse managers from each care unit to meet with her and representatives from nutrition and food services. They discussed the problem and discovered that most people viewed the food tray as a convenient disposal area.

Patients, especially those self-administering medications, had no qualms about putting trash on the food tray because they figured that everything on the tray would just be discarded. Patients about to be discharged were especially likely to view the tray as a convenient place to put trash. They assumed that the entire room would be cleaned after their departure, so they thought it didn’t much matter where they put a particular item of trash.

Clinical staff had a higher level of awareness that leaving medical waste on the tray was improper, but they often saw it as only minor deviation from good practice. In addition, staff often left items on the trays accidentally after setting them there temporarily for convenience and forgetting to remove them. The 90-minute discussion and root-cause analysis revealed these other root causes:

• The food trays came with a white paper place mat that sometimes made it hard to spot white gauze and other items.

• Fewer staff were around at meal times because employees took their meal breaks at about the same time. That meant that volunteers or other nonclinicians might pick up the trays and were less likely to spot the inappropriate materials.

• Staff often thought that nonsharps items could safely be left on the tray. If the staff member saw the item as harmless, he or she was more likely to leave it on the tray, even while being careful not to leave sharps.

• Sharps containers were not located as conveniently as needed in the rooms. Also, there was some inconsistency about where the containers were located in different rooms. This often caused the clinician to put the item on the food tray because it was conveniently located right in front of the patient, intending to pick it up and take it to the sharps container before leaving.

• Overworked nurses often had to multitask and became too busy to pay attention to proper procedures.

• Medications given at mealtimes increased the likelihood that medical wastes would be put on the trays.

Education plan makes a difference

Once the committee members identified the root causes, they worked out a number of solutions. The most important need was educating staff. "We put out the word that it was the staff’s responsibility to scan all trays and remove all foreign objects and patient care materials before sending them downstairs," Wilson says. "We had staff meetings with an educational story board put together by a manager in nutrition and food services, and they used a visual aid: a clear container full of all the things coming down with the food trays. They passed that around, and that was very effective," she explains.

These were some other educational initiatives:

• The nutrition supervisor put a reminder in the hospital newsletter.

• Flyers were posted on each nursing unit with the theme: "If it didn’t come up on the tray, it shouldn’t come down on the tray."

• The nursing director sent e-mail reminders to nurse managers.

Staff were receptive and eager to help once they heard how much the patient care materials bothered employees in nutrition and food services, Wilson says. Other measures were instituted to minimize the problem and track the process improvement.

The dietary aide who loads the used trays on a dumbwaiter to be sent down to food services was instructed to scan all the trays before loading them, she explains. If the aide spotted any patient care materials that the nurses had missed, he or she was not to remove them, she explains. Instead, the tray was flagged with a pink slip and sent back to the nursing station. "The idea was to make it a very visible reminder," Wilson says. "I’m sure it was a little annoying to have the tray sent back to the nurses, but that was sort of the idea. It made them much more aware."

The nutrition and food services department kept track of how many trays were flagged with a pink slip, plus how many trays made it down to their department with foreign materials. The committee also recognized that patients should be educated about why patient care materials should not be put on food trays, but members decided to let the nurses tackle that goal informally. If the other measures did not yield good results, more formal patient education might be the next step.

Other possible improvements were put on hold, too. The white place mats could be switched for a color that would make it easier to see white items, but the committee decided that change would be too expensive. It reached the same conclusion about the sharps containers. Even though they weren’t ideally located in each room, moving them would be a very expensive project. "It’s still something we could do, but we wanted to put that on hold until we saw whether these other changes would help," Wilson says.

Simple changes seemed to do the trick

All indications are that those more expensive changes won’t be necessary. Right after the root-cause analysis, nutrition and food services reported about seven instances a week of medical waste on trays, somewhat fewer than before, though no one was keeping records then. The next week, the number of incidents fell to three or four, and then dropped to one or two instances per week.

"Now we’re having no reports at all," Wilson says. "The tracking system is good, and it looks like we’re not seeing any more materials make their way down to nutrition and food services."

Though it seems the problem has been whipped, she says, the staff intend to keep focusing on it. The committee presented its findings at the hospital’s leadership day, after which the employee health and infection control departments asked to join the effort. With those departments on board, the committee reconvened in April and decided at that point to wait on relocating the sharps containers, Wilson adds.

"We’ll keep tracking it through the summer at least," she says. "We’ve got some people coming and going with staff changes, so we want to make sure everyone gets the word. After that, we’ll probably spot check it once a quarter and take corrective action if we start seeing the problem again."