NIOSH guidelines target disposal-related injuries

Part of total strategy for needlestick reduction

Emphasizing the need for an overall strategy to reduce needlesticks, the National Institute for Occupational Safety and Health (NIOSH) has targeted sharps disposal-related injuries in its newly released guidelines for selecting, evaluating, and using sharps disposal containers.

The document points out that more than 5.6 million health care workers are at risk of occupational exposure to bloodborne pathogens, including HIV and hepatitis B and C, with the primary route of transmission being percutaneous injury from sharp devices and equipment.1 Studies show that at least 800,000 needlestick injuries (NSIs) occur in hospitals annually,2 with as many as one-third of all sharps injuries estimated to be related to the disposal process.3

NIOSH, a branch of the U.S. Centers for Disease Control and Prevention (CDC), says factors most often associated with disposal-related injuries are inadequate design or inappropriate placement of sharps disposal containers, overfilling sharps disposal containers, and inappropriate sharps disposal practices by users during patient care. To prevent needlestick injuries, the guidelines recommend that hospitals adopt a three-pronged overall strategy:

· engineering controls, such as the use of safer needle devices;

· organizational controls, such as eliminating unnecessary sharps and training HCWs in the use of sharps disposal containers;

· NSI surveillance to assess NSI frequency and circumstances.

The document emphasizes that correct and consistent use of rigid sharps disposal containers in health care environments has been demonstrated to reduce NSIs.4 Placing disposal boxes in all patient and treatment rooms decreases NSIs, it states. In issuing the guidelines, NIOSH intends to provide a framework for selecting sharps disposal containers and evaluating their efficacy as part of an overall NSI prevention plan.

"Sharps disposal containers have been in hospitals and other health care facilities for a very long time, and there probably has not been very much re-evaluation of where they're placed and how they're used," says Linda Martin, PhD, director of NIOSH HIV activity. "This will encourage facilities to go back and assess the risks of disposal-related injuries. It will help them evaluate the problems and provide some solutions. When the CDC publishes something, it gives leverage for occupational health practitioners, infection control practitioners, and others to go back and say this has been recommended as a public health procedure, that we should evaluate our disposal-related injuries and see if we can help reduce them."

The document also can be used to guide new disposal container purchases and placement, Martin says.

Much of the information already is "out there," she adds, but NIOSH has compiled and widely distributed it to health care facilities.

Comparing NSI data from 1986, "when disposal systems were primitive and boxes were located at nurses' stations," to more recent data shows that "good disposal systems can reduce risks considerably, but it's one part of an overall program," says Janine Jagger, PhD, MPH, director of the International Health Care Worker Safety Research and Resource Center at the University of Virginia Medical Center in Charlottesville. "I think it's important, as long as institutions don't stop at that point, thinking they have improved their disposal systems so they've done everything they're going to do."

Jagger, who operates the Exposure Prevention and Information Network (EPINet) data collection system for assessing and identifying injury-causing needle and sharps devices, says percutaneous injury rates will be most affected by hospitals' transition to safer devices.

"The CDC did a landmark study on device evaluation,5,6 and that was very important. We need to continue that kind of work to be able to have ammunition to present to hospitals to say, 'How can you not use these devices when we have evidence about their performance?' It's also important for hospitals to have good disposal systems and a document to refer to in reviewing those systems," she adds.

'Potential for injury always there'

While noting that completely engineering out sharps and their associated hazards to HCWs is the ultimate solution, "it's not something that can be [accomplished] right now," Martin says. "Anytime you have a sharp object that has to be disposed of, the potential for injury is always going to be there."

Historically, the injury potential of sharps containers was worse at first when hospital officials feared that used sharps would be stolen by drug addicts if containers were visible, she explains. For that reason, designs were more security-oriented, but also had the effect of being more hazardous to HCWs. Sharps such as butterfly needles on IV tubing had a tendency to get stuck on phalanges around container openings, and workers sometimes had to push the sharps down into the boxes with their hands, a risky practice.

Also, containers often were placed in bathrooms instead of in patient rooms. When they were brought out in the open, some people didn't know what they were because they weren't labeled properly. Martin notes that in some cases, disposal boxes designed with flap openings were mistaken for mailboxes.

The guidelines establish four performance criteria for sharps disposal container safety performance: functionality, accessibility, visibility, and accommodation. (See details in related story, p. 63, and illustration, p. 64.) However, Martin emphasizes that every facility should evaluate its sharps disposal needs on a "case-by-case and area-by-area basis, because one container that's right for an emergency room might not be right for a patient care room. Criteria change, needs change, designs change, sharps change," she says.

Therefore, NIOSH recommends selecting a disposal container or combination of containers based on a site-specific hazard analysis with the following components:

· assessment of workplace hazards (biological, physical, chemical, and radiological containment 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.

A decision logic included in the document outlines appropriate criteria and priorities for selecting a container. (See chart, p. 62.) It can be used alone or in conjunction with a performance evaluation questionnaire (see questionnaire, inserted in this issue) to frame the selection process. Although it is not possible to provide precise guidelines for evaluating questionnaire scores, the guidelines state that the lower the score, the better the sharps disposal container (i.e., the highest score would be 44 points and the lowest would be 220 points).

An individual or group should be assigned responsibility for regular monitoring and maintenance of containers, including checking fill levels and making sure containers are changed before they are overfilled.

Before introducing a new sharps disposal container, worker training should be conducted to address its proper use. Training should involve all workers who might come into contact with sharps, including maintenance and laundry service staff.

"We hope that facilities will use this for their own purposes and develop more quantitative criteria for what is important specifically for them," Martin says. "This is general qualitative criteria, and some might not fit the needs of the institution. But it gives facilities the information to do a risk assessment in areas where sharps are disposed of and helps to solidify the evaluation process."


1. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Selecting, Evaluating, and Using Sharps Disposal Containers. Atlanta; January 1998.

2. Jagger J. Preventing HIV transmission in health care workers with safer needle devices. Paper presented at the Sixth International Conference on AIDS. San Francisco; 1990.

3. McCormick RD, Maki DG. Epidemiology of needle stick injuries in hospital personnel. Am J Med 1991; 70:928-932.

4. Haiduven DJ, DeMaio TM, Stevens DA. A five-year study of needlestick injuries: A significant reduction associated with communications, education, and convenient placement of sharps containers. Infect Control Hosp Epidemiol 1992;13:265-271.

5. Centers for Disease Control and Prevention. Evaluation of safety devices for preventing percutaneous injuries among health-care workers during phlebotomy procedures - Minneapolis-St. Paul, New York City, and San Francisco, 1993-1995. MMWR 1997; 46:21-25.

6. Centers for Disease Control and Prevention. Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures - New York City, March 1993-June 1994. MMWR 1997; 46:25-29.