Disposal of contaminated materials in primary health care : Nursing assistance grants

Objective: to analyze how nurses who provide home care discard contaminated materials in primary health care. Methods: a descriptive study was carried out, with 42 nursing professionals working in 21 Basic Health Units of a capital city in the Northeast of Brazil. The statements were processed in the IRaMuTeQ and analyzed by the Descending Hierarchical Classification. Results: Three classes were obtained: Domiciliary Solid Residues produced during the domiciliary visit, How the dynamics of the attendance influence in the production of residues?, Responsibility for the production and Management of Solid Residual Domiciliary. Conclusion: There is a correct conception about the solid waste formation in the health services and consequent adequate disposal of the same, however there is a gap between the knowledge and the implementation of this action in the daily practice of these professionals. Descritores: Knowledge; Nursing; Health Care Waste; Primary Health Care.


INTRODUCTION
The advances in the Health Care Networks, and consequent increase in the number of health institutions, resulted directly in a greater generation of Health Care Waste (HCW).The generation of this waste is directly related to the type of care provided, and has been increasing according to the expansion of the care in its most diverse forms, arriving at the home of the users through home care and by the professionals of the Family Health Strategy (FHS)¹.
Home care is defined as a modality of action performed by members of the health team at home² (Ministerial Order No. 356, of February   20, 2002).This alternative care model directs the care and clinical treatment of several diseases and patients to their house, and can function as an auxiliary service or continuity of hospital care³.
There has been an expansion of this model of assistance in Europe, and the United States, which already has more than 30,000 service providers registered in the country 4 .The activities of this assistance modality are centered on programs that mainly serve elderly patients and/or those with difficulties to go to basic care units.Of particular note is the care given to patients with chronic, terminal and infectious-contagious diseases 5 .The study was approved by the Research Ethics Committee (CAAE: 18110614.1.0000.5214).
In order to preserve the identity of the participants, an alphanumeric system (NUR01 and TEC01).

RESULTS
Regarding the characterization of the professionals, the majority were female (83.3%), and were formed more than 15 years (45.2%), with only primary health care (52.4%).
From the statements of the subjects, starting from 42 Units of Initial Context (UIC), the software recognized the separation of the corpus in 192 Elementary Context Units (ECU), using 68.9% of the total corpus (Figure 1).

In the patient's home is very complicated, because we already go in an improvised car, with an improvised team and arrives there we have to improvise procedures and the place to throw trash as well. (NUR 18)
The structure is totally different, I have to take it if you want to use it.So I have to take a sharp punch box, but several teams make several visits during the week, so does each team keep their box?Why a box per visit does not give ... (TEC 05)

Management of Solid Residual Domiciliary
The contents seized in this class evidenced that nurses realize that despite being a small environment, there is a generation of waste within the dynamics of care to users at this level of care, however the support provided by the health unit still make feasible the completeness of all stages involved in the waste management flow.
The professionals expressed the importance of their action in relation to the waste management, however there is still an asymmetry between the perception and the integrated performance of the team in maintaining a continuous and safe flow according to the demands of these services.

DISCUSSION
Nursing professionals recognize the existence of a fragility in the workflow in home care, which seems to be related to the care environment, willing supplies and human resources.
UBS are small care environments that offer simple, basic care.Although the generation of resources in them may seem small, considering the number of units providing this service in Brazil (around 31,418), the generation of waste tends to be equivalent to large units 12 .
The main problem in this scenario is the dynamics of the waste stream produced within these service units.In addition, it is highlighted that the home environment is considered an extension of the UBS, thus being an environment of health care.
Health facilities are placed in makeshift places, which often do not have sufficient support for an adequate flow of such waste, with facilities that do not allow group storage, assistance and internal circulation areas that allow the transit of transportation of waste and external storage facilities 13 .In the studied municipality, there is no service that correctly disposes of these residues, being the same, although collected separately, has as final destination a common sanitary landfill.

When
This incorrect form of disposal exposes the environment and people who collect recyclable materials in this scenario to risks of contamination and accidents with puncture-sharp materials 15 .
Weave discussions about waste management within the primary health care can help to mitigate the potential impacts in the health of professionals, patients and the environment.
Nursing professionals, due to being in daily contact with the needs of their area of coverage and carrying out a large number of procedures at home, should attend to issues such as waste management 16 .

CONCLUSION
Solid waste is present in the care of patients cared for in the home, the perception of this reality is perceived among primary care nursing professionals.Because it is a home care, they acknowledge the existence of a fragility in the accomplishment of this workflow, which may be related to the care environment, to the willing supplies or human resources failure.
Recorded interviews had an average duration of 40 minutes and were later transcribed.At the end of each interview the participants were asked if they would like to leave the study or change their answers, but there were no withdrawals or changes.The statements, in turn, were grouped and formed a corpus, which had statistical treatment in the software IRaMuTeQ (acronym of Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires), analyzed on the basis of the Descending Hierarchical Classification (DHC)[9][10][11] .Then, key expressions were extracted from the interviewees' speeches, which complemented the CHD findings and allowed the delimitation of the speeches in "definitive classes".The analyzes were based on the Collective Subject Discourse method.
makes it difficult to manage waste correctly.These difficulties may be related to both the activities carried out within the patients' homes and the transport of the material to the BHU.In Brazil, there is legislation that provides a framework for the proper management of health waste and provides for the stages of waste management (306/04).However, although it has been in force for 10 years, this resolution does not integrate the peculiarities that involve the production of waste in primary care, and especially those in home care.The materials present in the generation of these residues are classified into the following groups: A-potentially infectious, B-chemicals, Cradioactive, D-common residues and E-sharps, proper handling of such wastes involve steps such as segregation, storage, identification, internal transportation, temporary storage, treatment, external storage, collection and external transportation and final disposal 14 .In the domicile scope, common waste is the most frequent, however, due to the procedures performed during the service there is a significant production of potentially contaminated materials.Potentially infectious, chemical and perforating agents generated during home care must be packaged and collected by the service providers themselves or by a person trained for such activity and the waste must be in a container compatible with the residue group 13 .