Selecting, Evaluating, and Using Sharps Disposal Containers U.S. Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health Atlanta, Georgia January, 1998 DHHS (NIOSH) Publication No. 97-111

A. Focus group input

B. Determining sharps disposal container installation height using standard ergonomics measurements

C. Decision logic for selecting sharps disposal containers

D. Questionnaire for evaluating sharps disposal container performance

E. Recommended reading

F. OSHA Hazard Information Bulletin: sharps disposal containers with needle removal features

FOREWORD

The Occupational Safety and Health Act of 1970 created the National Institute for Occupational Safety and Health (NIOSH). NIOSH is charged with identifying the causes of work-related diseases and injuries, evaluating the hazards of new technologies and work practices, creating ways to control hazards, and recommending occupational safety and health standards.

Occupational exposure to bloodborne pathogens (including the hepatitis B and C viruses [HBV and HCV] and the human immunodeficiency virus [HIV]) poses a significant risk to workers in the health care industry and related occupations. The primary route of exposure to bloodborne pathogens is accidental percutaneous injury caused by needlesticks (puncturing of the skin by a needle or similar sharp object). In the United States, approximately 800,000 needlestick injuries occur in hospitals annually—an average of one injury every 10 seconds. Studies have shown that many of these injuries occur after a sharp (needle or other sharp object) is used; as many as one-third of all sharps injuries have been reported to have occurred during disposal activities.

This document presents a comprehensive framework for selecting sharps disposal containers and evaluating their efficacy as part of an overall needlestick injury prevention plan. The correct and consistent use of rigid sharps disposal containers in the health care environment has been demonstrated to reduce needlestick injuries. This document reviews the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard and recommends containers on the basis of a site-specific hazard analysis. The document also establishes criteria and provides tools for evaluating the performance of sharps disposal containers.

No single container type meets the disposal containment needs for every facility, but this document establishes a basis for selecting sharps disposal containers that will decrease the risk of percutaneous sharps injury. Each day, thousands of dedicated men and women in health care and related industries risk their well-being to protect and improve the health of others. We must work together to ensure that their jobs are performed in a safe and healthful environment. This document is a valuable tool and an important part of a comprehensive strategy to reduce injury and illness in health care workers.

Linda Rosenstock, M.D., M.P.H.
Director, National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention

ABSTRACT

Occupational transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) has been well documented. The risk of infection with HIV following one needlestick exposure is approximately 0.3% and ranges from 6% to 30% for HBV and from 5% to 10% for HCV. The passage of the Occupational Safety and Health Administration's (OSHA's) bloodborne pathogens standard (29 CFR 1910.1030) has increased compliance and awareness of prevention strategies. No single sharps disposal container design meets all the disposal containment needs for all health care settings or for an entire hospital. Container selection should be based on a comprehensive site-specific hazard analysis.

The safety performance criteria for sharps disposal containers are divided into four areas. First, containers should remain functional during their entire use. They should be durable, leak resistant, and puncture resistant under all normal environmental conditions. Second, containers must be accessible to workers who use, maintain, or dispose of sharp devices. This criterion includes sufficient number, sufficient container volume, and safe access to the disposal opening on individual containers. Other important factors include convenient placement and (if necessary) portability of containers within the workplace. Third, containers should be visible to the workers who must use them. Container fill status and warning labels are also important visibility criteria. Fourth, container designs should accommodate the user, the facility, and the environment. Although engineering controls such as needleless IV systems and "safety" needles will reduce injuries, proper selection and use of sharps disposal containers are still important. Prevention strategies include implementing engineering controls, using personal protective equipment, training employees, and involving occupational health professionals and workers.

ACKNOWLEDGMENTS

The following individuals contributed to the development of this document:

Jacqueline Agnew, Ph.D., National Institute for Occupational Safety and Health (NIOSH) Educational Resource Center (ERC), Johns Hopkins University, Baltimore

Elaine Askari, M.P.H., NIOSH ERC, University of California, Berkeley

Scott Campbell, R.N., M.S.P.H., NIOSH ERC, University of Minnesota, Minneapolis

Scott Deitchman, M.D., M.P.H., Office of Extramural Coordination and Special Projects (OECSP), NIOSH, Centers for Disease Control and Prevention (CDC), Atlanta

George Delclos, M.D., M.P.H., NIOSH ERC, University of Texas, Houston

Sarah Felknor, M.S., NIOSH ERC, University of Texas, Houston

June Fisher, M.D., NIOSH ERC, University of California, San Francisco

Robyn Gershon, Dr. P.H., NIOSH ERC, Johns Hopkins University, Baltimore

Robert Gross, School of Engineering, Stanford University, Palo Alto

Keith Henry, M.D., NIOSH ERC, University of Minnesota, Minneapolis

Philip Johnson, M.D., NIOSH ERC, University of Texas, Houston

Christine Kasting, M.P.H., OECSP, NIOSH, CDC, Atlanta

Jane Lipscomb, R.N., Ph.D., Office of the Director, NIOSH, CDC, Washington, DC

Linda S. Martin, Ph.D., OECSP, NIOSH, CDC, Atlanta

Meryl Mendelson, M.D., NIOSH ERC, Mt. Sinai School of Medicine, New York City

Robert J. Mullan, M.D., OECSP, NIOSH, CDC, Atlanta

Louise Short, M.D., M.P.H., Hospital Infections Program, National Center for Infectious Diseases, CDC, Atlanta

James Spahr, R.S., M.P.H., Indian Medical Center, Phoenix

Andre Weltman, M.D., NIOSH ERC, Mt. Sinai School of Medicine, New York City

Drafts of this document have been reviewed by representatives of Federal agencies and labor and industrial groups. NIOSH thanks these individuals for their thoughtful comments, suggestions, and assistance.

PUBLIC HEALTH SUMMARY

What are the hazards?

Workers in the health care industry and related occupations are at risk of occupational exposure to blood borne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other potentially infectious agents.

How do these hazards occur?

The primary route of occupational exposure to bloodborne pathogens is accidental percutaneous (through the skin) injury. Health care workers handle sharp devices and equipment such as hypodermic and suture needles, intravenous blood collection devices, phlebotomy devices, and scalpels. Of the 800,000 needlestick injuries (NSIs) estimated to occur in the hospital setting annually, the greatest number occur to health care workers with the most involvement in direct patient care. Nursing staff and phlebotomists sustain the highest percentage of reported NSIs.

Hospital NSI studies have shown that many of these injuries occur after the device is used and during disposal activities. As many as onethird of all sharps injuries have been reported to be related to the disposal process. The factors most often related to sharps injuries include the following:

• Inadequate design or inappropriate placement of the sharps disposal container
• Overfilling of sharps disposal containers
• Inappropriate sharps disposal practices by the user during patient care

How can these hazards be avoided?

The use of safer needle-bearing products, worker education and training, other measures for preventing sharps injuries, and compliance with standard precautions for preventing exposure to bloodborne pathogens should be part of an overall strategy for preventing NSIs.

Important elements of an overall prevention strategy include the following:

• Engineering controls (an example is the use of safer needle-bearing products)
• Organizational controls (examples are the elimination of unnecessary sharps, and training in the use of sharps disposal containers)
• Surveillance of NSIs to assess their frequency and circumstances

The routine use of rigid sharps disposal containers in the health care environment has been demonstrated to reduce NSIs. This document presents a framework for selecting disposable and reusable sharps disposal containers and evaluating their efficacy as part of an NSI prevention plan.

Section I (A) of this document addresses four major criteria for evaluating the performance of sharps disposal containers.

1. Functionality: Containers should remain functional during their entire usage (i.e., they should be durable, closable, leak resistant on their sides and bottom, and puncture resistant until final disposal).

2. Accessibility: Containers should be accessible to workers who use, maintain, or dispose of sharp devices. Convenient place ment should also be considered, along with portability of containers within the workplace, if necessary.

3. Visibility: The following should be plainly visible to the workers who use the con tainers: the container, the degree to which it is full, the proper warning labels, and the color coding of the container.

4. Accommodation: Containers should be accommodating or convenient for the user and the facility and should be environmentally sound (e.g., free of heavy metals and composed of recycled materials).Accommodation also includes ease of stor age, assembly, and operation.

Appendix D contains a questionnaire designed to evaluate container performance based on these four performance criteria. This questionnaire should help product evaluation committees, facility management, and health care workers select and evaluate sharps disposal containers.

Section II (B) of this document presents requirements of the Occupational Safety and Health Administra tion (OSHA) and recommendations of the National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), concerning sharps disposal container selection and implementation. OSHA's bloodborne pathogens standard is reviewed to establish minimum design performance elements. Recommendations are made for reprocessing reusable sharps disposal containers.

NIOSH recommends selecting a container or com bination of containers that are based on a site-specific hazard analysis and have the following components:

• Assessment of workplace hazards (biological, physical, chemical, and radiological contain ment needs)
• Assessment of size and types of sharps to be disposed of
• Assessment of the volume of sharps to be disposed of at each point of use
• Assessment of frequency of sharps disposal container emptying and mounting bracket servicing by maintenance staff
• Compliance with Federal, State, and local regulations
• Security requirements
• Container transport or mobility needs
• Clinician and procedural variability and movement
• Laboratory equipment variability and movement
• Environmental and disposal constraints
• Cost considerations
• Continued evaluation of medical device technology, including ongoing changes in equipment design and barrier materials

Appendix C presents a decision logic outlining ap propriate criteria and priorities for selecting a sharps disposal container. This decision logic can be used alone or in conjunction with the performance evaluation questionnaire (Appendix D) to frame the selection process.

Sharps disposal containers that are functional, accessible, secure from patient and visitor tampering (if necessary), visible, and convenient to use will de crease the risk of percutaneous sharps injury. There is no single container type that meets the disposal containment needs for an entire facility. The diversity of health care settings and procedures makes selecting a single container impossible.

Where can I get more information?

The references and related reading list at the end of this document provide a useful inventory of published reports and literature. If you have any questions about obtaining equipment described here, contact your local biohazard safety/waste equipment supplier or call NIOSH.

Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.