Evolving Sharps Management
Reusable sharps containers protect health care workers, patients and the environment.
ANN MARIE Pettis, director of infection prevention at the University of Rochester Medical Center, remembers using empty orange juice cartons with the tops removed and open mayonnaise jars to dispose of sharp objects in various clinical settings early on in her career of 30-plus years. Why? Because “there was no other alternative.”
After the orange juice cartons came the first wall-mounted container with an envelope-style disposal. However, once it became overfilled with syringes that sat on the lid or popped out, sharps injuries and infection risk were inevitable.
Today Pettis recognizes how far the sharps container industry has evolved. Her priorities include health care worker safety and disease transmission prevention. Between policy and persuasion, the container industry began including human factors into solutions engineering to innovate new designs that prevented regular tipping and spilling of contents.
In 2000, the Needlestick Safety and Prevention Act was introduced and led to a 31.6 percent overall reduction in needlestick injuries in nonsurgical settings.1 However, the Centers for Disease Control and Prevention estimates that approximately 385,000 needlestick and sharps-related injuries still occur every year to health care workers in hospital settings.2 Average costs for testing, follow-up and preventive treatment range from $375–$2,500,3 but some experts believe the average costs of a needlestick, excluding treatment, is almost double the CDC estimate.
According to Pettis, a large percentage of bloodborne exposures at her facilities at this point is from blood and body fluid splashes. “If there is a needlestick injury, it typically occurs while recapping the sharp or when the sharp is left after use for another unwitting staff member to clean up a procedure area.”
ONE SOLUTION? REUSABLE SHARPS CONTAINERS
When reusable sharps containers were first proposed at her organization, Pettis initially had concerns about the possibility of environmental contamination and subsequent disease transmission. After receiving a thorough overview of the container disinfection process, her fears were allayed.
It is estimated that more than 2.36 million sharps containers of all types are in use at U.S. hospitals.4 This figure does not include sharps container usage in nursing homes, clinics, physician offices or other health facilities. Of these, 30 percent or more are reusable, processed by outsourced companies who collect within institutions, transport, disinfect, deliver and replace reusable sharps containers.
Today, health care providers have many container choices, including reusable sharps containers that meet OSHA standard 1910.1030(d)(4)(iii)(A) and are closeable, puncture resistant, leakproof and affixed with warning labels. Additionally, the containers Pettis’ team chose have FDA 510(k)-market clearance as Class II medical devices (a noncritical care item). According to the Spaulding Classification, this type of device requires low-level disinfection, but the vendor goes beyond and disinfects the containers to an intermediate level. This type of container promotes health care worker safety with an easy-to-see fill status.
CONTROVERSY DÉJÀ VU
In June 2015, a poster session (www.bd.com/sharps/pdf/AJIC-MP-sharps-poster.pdf) at the Association for Professionals in Infection Control and Epidemiology annual conference found an association between a higher rate of C. difficile infection and facilities that had established a reusable sharps container system.5 This stirred opinions in facilities of all sizes about the potential risk of transmission of C. difficile infections from reusable sharps containers. A press release led to the survey being quoted in mainstream publications.
However, this is déjà vu as an earlier study in 2007 alleged contamination of reusable containers delivered to client facilities—including some detection of bloodborne pathogens. A review of this evidence provided context and epidemiologic perspectives that questioned the study’s validity and reproducibility.6
The same context and perspective is needed for this new finding,5 which involved a survey of facilities and then cross responses with claims-based incidence of C. difficile infection. While there was an association with facilities that had reusable containers, association does not prove causation. Moreover, a number of other variables were not captured, such as level of adherence with hand hygiene, use of personal protective equipment for isolation precautions, the presence or absence of an antimicrobial stewardship program and more. More investigation is needed to validate this association—including a laboratory study of containers. It is also very unlikely that personnel would have contact with a sharps container prior to delivering direct patient care, so the biological plausibility of spread from the container to the patient would need to be investigated.
In its 2015 Sustainability Benchmark Report,7 Practice Greenhealth provided that closer look, reporting that based upon further inspection of the survey by Stericycle,4 there was an “overall lack of proper scientific methodology” ranging from “small sample size/survey response” to absence of an accompanying laboratory investigation to detect C. difficile spores on containers. The organization’s advice is that hospitals should be careful to do their due diligence before any consideration of changing back to disposable sharps containers.
“When I first read about the survey, I was intrigued by the suggested correlation, but after reviewing the methods, the tentative conclusion seemed like a bit of a leap,” said Pettis.
For Pettis and many of her colleagues, what was most puzzling was how transmission of C. diff could occur from reusable sharps containers since they are not high-touch items for patients or staff. “What ends up inside the container should stay there,” she said. “Because environmental services workers wear gloves when handling sharps containers and a third-party partner changes near-full containers, we were skeptical of the association between the containers and an increased incidence of C. diff. A title like this for a journal article certainly piques your interest, but more rigorous scientific evidence is desirable.”
While safety and prevention of disease transmission are top priorities, Pettis and her peers agree that reuse makes sense. Reusable sharps containers have contributed to their organization reaching its sustainability goals.
With these containers, Strong Memorial Hospital and Highland Hospital combined now annually prevent 126,485 pounds of CO2 emissions by keeping 216,814 pounds of plastic and 9,600 pounds of cardboard from landfills.8 These numbers are equivalent to not burning 6,514 gallons of gas or 2,392 tanks of propane gas for barbecues.
Pettis, many of her peers and multiple third-party organizations throughout health care agree: Reusable sharps containers are safer for health care workers, patients and the environment than any current alternative for sharps disposal. While it is imperative that the industry continues to innovate and explore better solutions in all areas of hospital management and patient care, when it comes to sharps management, reusable sharps containers are the best solution for the market today.
Disclaimer: Strong Memorial Hospital and Highland Hospital use the Stericycle Sharps Management Service.
2. www.cdc.gov/niosh/stopsticks/sharpsinjuries.html, 2004
3. Science Daily, “Sharps’ Injuries Have Major Health and Cost Impact for Surgeons,” www.sciencedaily.com/releases/2013/04/130402101144.htm, April 2, 2013
4. Garcia, R and Olmsted, R. “Reusable Sharps Containers: An epidemiologic perspective for the infection control professional.” Stericycle, 2015
5. Pogorzelska-Maziarz, M. “Relationship between sharps disposal containers and Clostridium difficile infections in acute care hospitals.” Am J Infect Control. 2015 Oct 1;43(10):1081-5
6. Runner, JC. “Bacterial and viral contamination of reusable sharps containers in a community hospital setting.” Am J Infect Control. 2007 Oct;35(8):527-30