The control of substances hazardous to health

Following its April event on hazardous substances in healthcare, Karen Cunningham, from the IOSH Health and Social Care Group, explains how risks presented by hazardous substances are managed by Belfast Health and Social Care Trust.

It is important that robust COSHH (control of substances hazardous to health) Management Systems are put in place to manage the potential risks associated with staff exposure to hazardous substances arising out of the delivery of healthcare services.

There are many risks in the industry which must be considered. They may include: exposure to waste anaesthetic gases; manually cleaning/decontaminating medical devices and surfaces; preparation, handling, administration, reconstitution and disposal of cytotoxics and other pharmaceuticals; the clinical care of patients with infectious diseases; exposure to non-medical gases such as liquid nitrogen, argon, carbon dioxide, helium and nitrogen; dusts associated with casting materials; the use and disposal of sharps instrumentation; the use, handling and storage of medical gas cylinders; substances used to preserve and fix specimens and tissues; substances used for surgical hand disinfection and skin cleaning prior to procedures; potential exposure to natural rubber latex containing products; substances associated with engineering, prosthetics and other workshops; handling and transporting dangerous goods; and dusts associated with baking.

Legislative changes
In addition to the requirements of the COSHH Regulations and associated approved code of practice, recent legislative changes have introduced new responsibilities.

One of these is the Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH) 2007. This relates to the registration of substances with the European Chemicals Agency; the introduction of ‘downstream user’ responsibilities; additional information in safety data sheets; restriction/reclassification of chemicals; the introduction of DMELs (derived minimal exposure levels), DNELs (derived no effect levels) and PNECs (predicted no effect concentrations); substances of very high concern; and reclassification of formaldehyde as a Class 1B carcinogen.

The other is the Classification, Labelling and Packaging for Supply (CLP) Regulations 2009 (amended 2015). This relates to the replacement of previous CHIP Regulations, the introduction of Hazard Statements (replacing Risk Phrases), new Global Harmonised System (GHS) – warning symbols, and reclassification of substances under CLP following evaluation through the REACH process.

Belfast Health and Social Care Trust
Belfast Health and Social Care Trust delivers integrated health and social care to approximately 340,000 citizens in Belfast and provides a range of specialist services for the population of Northern Ireland. With a workforce around 22,000, they are one of the largest trusts in the United Kingdom.
The trust, through the provision of its services, uses a wide range of hazardous substances which fall under the scope of the COSHH regulations. Services delivered include cardiology, anaesthetics and theatre services, medicine and neurosciences, cancer services, nephrology and transplant services, rheumatology, dermatology services, maternity and women’s services, dentistry and child health, trauma and orthopaedics and adult and children’s community services.

COSHH Working Group and procurement
The trust has established a COSHH Working Group, reporting to the Joint Health and Safety Committee, which forms part of the trust’s assurance structure, with membership across the directorates and from the procurement and logistics services. This working group has many functions. It must identify high-risk substances currently in use within the trust and determine effective trust-wide management arrangement for elimination, substitution or safe control. It develops a formal procedure for service areas/COSHH assessors to manage ‘substances of very high concern’ and the future procurement of hazardous substances, with a significant emphasis on safer alternatives. It prioritises the substitution of substances with carcinogenic constituents from use within the trust. It also ensures the potential health effects of procured products are considered at the contract stage in addition to elimination and substitution of high-risk substances.

In addition, its role is also to revise the trust’s policy (and amend the COSHH policy accordingly) on the use of high-risk substances (e.g. substances which cause cancer, heritable genetic damage or asthma). It is also to further investigate if safer processes/substances are available, as well as consider the benefits for procuring a chemical management system for the trust in light of the recent registrations and reclassifications of chemicals products under the REACH regulations and subsequent changes to the role of the COSHH Risk Assessor.

It worked in conjunction with Procurement Services to introduce safer needle devices to all areas of the trust in order to reduce sharps injuries associated with use and disposal, through a Safer Needle Devices Group.

Risk assessments and policies
There are also a number of risk assessors working together to develop COSHH risk assessments for their services in various departments. A standard COSHH risk assessment template is used throughout the trust. Sample risk assessments have been created for assessors’ reference, accessible through the trust’s intranet, together with COSHH guidance notes, flowchart and inventory.

It identified the use of non-medical (asphyxiant) gases associated with particular processes and pieces of equipment and raised the need for COSHH risk assessments and associated controls to be put in place. The management of these gases now form part of the terms of reference of the Medical Gases Committee.

The trust has developed and continues to review a number of policies and supporting documentation on, for example, COSHH, Prevention and Management of Latex Sensitisation, Management of Tuberculosis Policy and New and Expectant Mothers.

Inspections and auditing
The trust undertakes health and safety of particular services focused on the management of hazardous substances, resulting in recommendations including improvements in strategies for occupational exposure monitoring, arrangements for future procurement and the elimination of substances of very high concern.

It has developed and implemented a Belfast Risk, Audit and Assessment Tool (BRAAT) – a self-assessment tool to assist trust service areas establish their level of compliance with the trust’s health and safety policies including COSHH. The resultant action plan is used to assist service areas address any outstanding issues and links with the trust’s Risk Register process. Service areas’ submitted scores may be randomly selected for a validation visit.

The trust has a team of four health and safety managers, who are Chartered members of the Institution of Occupational Safety and Health (IOSH). They provide advice and support to partnered directorates and COSHH risk assessors.

Evidence to demonstrative substantive compliance with regional health and social care health and safety audit criterion, known as Controls Assurance, is submitted on an annual basis. Dangerous goods safety advisers have been appointed in laboratories and medical physics and a multi-professional scoping exercise was completed to establish the trust’s compliance with the Carriage of Dangerous Goods (ADR) legislation.

Communication and training
The health and safety team introduced three key themes to raise awareness of the need for service areas to audit their health and safety management systems, one of which was to reduce needle stick injuries. These themes continue to be highlighted to managers and staff at all trust health fairs.

COSHH-related issues regularly feature in the internal quarterly newsletter, Safety Matters, for example assessing risk from exposure to biological agents, respiratory health surveillance and managing risks associated with working with asphyxiant gases. A new quarterly COSHH update was introduced to inform trust COSHH risk assessors of changes in legislative requirement, revisions to policies, guidance and associated documentation.

Safety Message of the Week, featured on the trust’s intranet, has included an article on raising awareness of the circumstances in which exposure monitoring may form part of a COSHH risk assessment.

The trust has organised several IOSH modern COSHH management courses for the estates, pharmacy and health and safety staff. A professional development event in conjunction with the IOSH Health and Social Care Committee on hazardous substances in healthcare was held in the trust in April 2016.

The trust’s Statutory/Mandatory Training Matrix includes three courses. They are: COSHH Awareness, which is required to be completed by all relevant staff every three years; COSHH Risk Assessment for all nominated COSHH Assessors (initial training); and COSHH Risk Assessment Refresher for all trained COSHH Assessors every three years.

Healthcare award
The trust participates in external benchmarking through the All Ireland Annual Occupational Health and Safety Award Process and in 2015 was awarded the NISO/NISG All Ireland Healthcare Award. The entry submission included sections on hazard identification and risk management, health and safety training and proactive health and safety management.

The trust continues to implement and review systems to manage hazardous substances associated with the delivery of its services.

Karen Cunningham is Lead Health and Safety Manager in the Belfast Health and Social Care Trust. She previously worked for a number of healthcare providers.

She is a chartered member of the Institution of Occupational Safety and Health (IOSH), the world’s largest membership organisation for safety and health professionals. She is a member of IOSH’s Health and Social Care Group committee, which helps professionals within that industry network and share best practice.

Further information