The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
Episode #17 Managing Sharps Disposal in Your Practice
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If you've never given any thought about your sharps containers, other than "out of sight, out of mind", then tune into this week's episode. The Divas discuss the required elements for secure and safe sharps disposal along with what actually can and cannot be placed in a sharps container.
Welcome. I'm Leslie Cannum. I'm Mary Gavoni.
SPEAKER_03I'm Linda Harvey. I'm Olivia Juan, and together we are the Compliance Divas. Hello everyone, and welcome to this episode by the Compliance Divas about Sharps containers and safety. We bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website, thecompliancedivas.com. Resources we mentioned during this podcast can be found on the compliancedeva.com website. And you are most welcome to submit your questions to support at thecompliancedeva.com. So this week we're talking about sharps injuries and sharps disposal and focusing specifically on sharps containers. Improper disposal of sharps is a significant cause of sharps injury. This includes inappropriate sharps disposal practices such as insufficient maintenance of sharps containers, overfilled, incorrect sharps disposal procedures, and insufficient selection and placement. Over the years, as a consultant, I have seen numerous citations associated with Sharps containers. So we thought this would be great content to share with our listeners. Let's start with our diva, Mary. Mary, what can you tell us about the critical elements needed for secure and safe Sharps disposal containers?
SPEAKER_01Thanks, Olivia. One of the most important things about a Sharps container, which many of our listeners may not be aware, is that they're actually regulated by the Food and Drug Administration. So the FDA clears, that's the term that they use for their approval process. And Sharps containers must have submitted information to the FDA to show that they're effective and they meet the criteria to be sold as a sharps container. So that's a very important thing to know that our listeners should always make sure that they're buying their sharps containers through a recognized, meaning within the dental or medical profession, a recognized supplier so that they know that they're going to have these FDA-approved devices. So the FDA says that sharps disposal containers, first of all, must be made of heavy-duty plastic. So they're not going to be, they're going to be rupture-proof for the most part. You have to be able to close them with a tight-fitting, puncture-resistant lid, and sharps should not be able to protrude out of that once you close the lid. They need to be upright and stable during use. So they wouldn't fall over and the contents would spill out. They need to be leak resistant for obvious reasons, and they have to be properly labeled to warn that there is hazardous waste in the container. And that typically is done with a biohazard label. And I think many people see outside of healthcare now sharps containers in restrooms for anyone who perhaps is diabetic and has to inject while they're away from home and so forth. And those are probably much more tamper resistant for obvious reasons than what we see in dentistry. We usually have them a little more freestanding, perhaps on a countertop or in a sterilization instrument processing area. I do still see some practices using like milk jugs or um coffee cans, other types of devices as sharps containers. And just be aware, again, that you must be using an FDA cleared sharps container. And if you have a sharps disposal service that you use to dispose of your containers, they will probably let you know if you're not using an appropriate container because they have to be responsible for those items during shipment.
SPEAKER_03Thank you, Mary, for your insight. And some years back, NIOSH used focus groups to determine the critical elements needed for secure and safe sharps disposal. And they came up with those four elements of functionality, accessibility, visibility, and accommodation. Linda, what can you talk to us about regarding the location of sharps containers and why we would place them in certain locations?
SPEAKER_02Thank you, Olivia. That's actually a very interesting question and an important point to think about because in a dental setting, we typically rely on aesthetic factors as to where we end up placing our sharps containers. More times than not, we like the countertops clear because of the aerosol spray and splatter. And usually we have other things sitting on the counter that we need more frequently. And we want those sharps containers tucked away someplace safely. And this whole component of where the placement should be falls under that accessibility criteria that you just mentioned. In addition, as Mary was talking about, with a regulation with the FDA and so forth, there's a guidance document from NIOSH, the National Institute of Occupational Safety and Health, which is under the CDC, that reference that OSHA references for compliance in their documentation. And in specific, OSHA references this in their compliance directives to their inspectors. And in a compliance directive, think of it as the instructions that an OSHA inspector would use when going out and inspecting any healthcare office. And of course, including the Sharps component would be assessed as well. So that leads us to the question: where should they be placed under these safety guidelines? Well, they should be placed where there's no obstacles between the user and the container. So no furniture, no difficulty in reaching and leaning over. There should not be near light switches, should not be near pedestrian traffic. And only in certain situations can we use innovative sharps disposal placement. And that's specifically mentioned in this guidance document with related to pediatric and geriatric facilities. So typically we don't have a geriatric-focused dental practice, but we do have pediatric-focused dental practices that might have some special considerations so that these Sharps containers aren't in the line of traffic for pediatric patients. So in addition to making sure that there's no unsafe location that would force the worker to make an unnecessary movement, either when holding the sharp or when accessing the container, were some other considerations as well. And that is the installation height of the device. So think back to any time you've been into a medical office and you see the sharps container attached to the wall. That's where they really ideally should be. And I know that in a dental setting, we like to have this, you know, calming, soothing environment that's very aesthetically pleasing. And when you start putting sharps containers and different things attached to the wall, it feels more like a clinic than a private practice that would like to have more of a spa-like, relaxing feel for the patients when they come into the practice. So these sharps containers should be placed within arm's reach and just below their eye level at their point of use. And the documents particularly recommend and state that the fixtures should be below the eye level of 95% of your adult female workers. Now that might sound a little odd, but just think about it: a lot of gentlemen are taller. And therefore, someone who's more petite would have trouble reaching in or seeing when they're disposing the sharp into the sharp's container. So again, it should be placed within arm's reach below the eye level, and it should be within 56 to 52 inches at the standing position above the floor. And then a sitting workstation would be 42 inches to 38 inches if someone's again seated. So those are the ranges of where it should be attached to the wall. And this is something new that we probably have not been aware of in dentistry as much as we should have. And this is very important. Again, it's mentioned in the OSHA guidance documents, it's mentioned in the NIOSH guidance, and in addition, it's mentioned in the blood-borne pathogen standard. And those are all areas that an OSHA inspector would be looking for when they make an inspection of a practice. So Sharp's container has to be visible in the device, the color has to be red or fluster fluorescent red or yellow, or red, yellow, pardon me, orange color rather, and have the warning label on it and has to visibly be able to see the fill status of the containers. So the team member will know when it's time to change it and they're not trying to overflow uh the device, which could lead to a sharps injury. So, Olivia, those are some things that we should consider in all practice. This totally turns what we've been doing on our head, doesn't it?
SPEAKER_03It does. And I appreciated your comments. I too prefer to see them mounted on the wall. And I get the same response from clients that you do that they're trying to make the office look beautiful. And the last thing they want to look at or have patients look at is a sharps container. However, I point out that you know this is not a hair salon. This is not a spa. It is still a healthcare facility, and we must align ourselves with these safety standards. And I remember, Linda, some years back I worked with a client and we did a mock audit, as you all also do with your clients. And the dental practice made most of the changes that we suggested in their work plan, except movement of the sharps container. The uh dentist preferred to have it hidden behind a cabinet. And so, you know, of course, that's there's nothing we can do to make those changes, but we had suggested it. And ironically enough, some months later, this practice was randomly audited, and the OSHA inspector cited the location of the sharps container. So I really appreciate you, Linda, pointing out the ideal locations. This really is not optional. It has to promote safety. Mary, what other suggestions do you have?
SPEAKER_01Well, I uh concur with what you've said about having it mounted on the wall, especially if you are a specialty practice and doing some um IM sedation. I've had a couple of oral surgery practices that I've worked with that have actually had their countertop sharps containers stolen from the practice. Now, how do you get a big sharps container out of the practice? I don't know, but they found them missing um a couple of times. And so somebody's after the syringe, perhaps after what any residual medications might be there. So I would say, especially in those situations, they do need to be mounted on the wall. And I love what you said. It's not a hair salon, it's a healthcare facility, and we have to view it as that, especially if we want our patients to take us seriously.
SPEAKER_03Uh good points, Mary. Leslie, our next diva, talk to us about what exactly goes into the sharps container and what does not go in the sharp's container.
SPEAKER_00Certainly, Olivia. Anything sharp. So needles and syringes, uh, we have uh endophiles, we have broken instruments that might be sharp, broken glass, certainly, uh, scalpels, just about everything that is sharp that's contaminated, should be placed in the sharp's container as soon as it is done being used, so we don't have to transport it to another location. And when I think sometimes about some practices that are not really sure if they uh have sharps, um, for ortho practices, uh orthodontic wires are considered sharps. There's actually a letter that has been written to an orthodontist from OSHA that describes that being sharps, that the ortho wires and and uh orthodontic or arch wires are considered sharps as well. Now, um, sometimes we find that we want to put all sorts of things in the sharps container. Those of us who have sharps containers that are picked up, we can end up filling up our sharps containers with lots of unnecessary items. And so I would encourage you to uh when you're thinking about what to put in the sharps container, uh, decide whether it's actually sharps or whether it's actually uh trash or whether it's biohazard waste or whether it's pharmaceutical waste. One of the most frequently asked questions I hear, what about anesthetic carpules? Well, um, empty anesthetic carpuls can become broken glass. Anesthetic carpules that have some anesthetic in it are actually pharmaceutical waste. And the guidance surrounding disposal of pharmaceutical waste varies from state to state. In some states, for example, my own in California, if there is more than 3% anesthetic left in the carpole, it's considered to be pharmaceutical waste and it can't be placed in the sharps container. Um, one mistake that many dental practitioners made throughout the years is that they would express what was in the anesthetic carpole out, like onto a cotton roll or into the sink or on a paper towel and then throw that out. And again, that uh becomes an EPA issue. And depending on what your guidance is in your area, uh, you might find yourself facing a citation. I know someone that uh I met at a dental conference had a citation exactly like that. So uh be mindful of the different types of waste that you have. Uh, one way that I've been, I guess you could say since uh my training as a young dental assistant, how I determined uh whether something was biohazard waste or whether it was regular trash. Uh, if you have gauze or cotton rolls that would drip blood if you pick them up with the cotton pliers, uh, or uh if you had any kind of uh anything you use in the patient's mouth, sometimes we use uh dry angles or other things that if they drip blood when picked up with a cotton plier, then they can't go in the sharps container. They're really considered biohazard waste and they go into your red bag. And if a uh gauze or or cotton roll or whatever you used um will flake dried blood, if you shake it, pick it up and shake it with a cotton plier, that also should not go into the sharps container. That should go into biohazard waste. And uh sometimes we are looking at at waste that can simply go in the trash. So uh that's a whole nother topic for another podcast, but you know, in avoiding what we do not want to put into the sharps container, we don't want to fill it up with uh uh gauze or exam gloves or anything that we use on the treatment flat tray like cotton rolls. We don't want to put medications in there. Uh we don't want to put aerosols or inhalers, um, garbage, batteries, uh, we don't want to put anything that is containing mercury. So sometimes we have um a chunk of mercury that or a chunk of amalgam that may come from a patient's um mouth or extracted teeth. Now, extracted teeth, it would seem like the sharps container would be an ideal place to put them. But just think for a moment, if you have a badly infected uh tooth that is extracted, and you put that puppy in the sharps container in the treatment room, after a few days, it's gonna start to smell a little ripe. So we want to be mindful of what goes in there. Uh, we also don't want to put uh hazardous waste or hazardous chemicals into that sharps container.
SPEAKER_03Olivia? Thank you for your insight, Leslie. That's very, very helpful. Mary, how are sharps containers commonly disposed of?
SPEAKER_01Thanks, Olivia. Um, there's a couple of issues we have to look at when we talk about disposal of sharps containers. Um, most dental practices use a service to dispose of their sharps containers. It may be a mail-in service where they get special packaging. They these packages have to be triple, um, triple packaged, meaning a box and a box and a box for the sharps container to be shipped, and then they're shipped off-site, and that hazardous waste company will dispose of them, which I'll talk about in a minute. Or they have a company that comes to pick them up from their practice, a hazardous waste company. And then there are some practices that will utilize maybe a local hospital that they transport their sharps containers to the local hospital, which you have to make sure if you're doing that, that you investigate and validate what your local medical waste laws are, because that actually makes you a transporter of medical waste. And so you have to be careful about that. There are other states that will allow Sharps containers to actually be transported to a landfill, which again, I'm not a big fan of because you may not get the appropriate documentation that you need. And when it's going from your practice to the landfill, you are the transporter of medical waste. And there could be some interesting violations there. So you're better off using a service that is licensed to do that for you. And then once they get to the licensed waste hauler site, they're they can either be put through a large autoclave sterilized and maybe ground up and sent to a landfill. But what happens more commonly is that they're incinerated. So when Leslie was talking about EPA regulations and what goes in the sharps container, you have to be aware of how your sharps containers are disposed of so that you know what is appropriate and not appropriate to put in that sharps container, especially pharmaceuticals. And that's been a development within the last several years that have those have been banned from sharps containers, especially where they're incinerated, and amalgam because those can pose environmental hazards. The other thing that a lot of practices that I work with aren't aware of initially, when you dispose of your sharps containers, if you're using either a mail-in service or a pickup service, first of all, you have to make sure that in your state there isn't some particular timeline for you to have to dispose of those. Many states allow sharps containers to be disposed of whenever they're full. And then you schedule a pickup, or other states, Michigan is one of those, that says your sharps containers must be removed from your facility every 90 days. So whether they're full or not. So for some people in the last few months, as there has been a shortage of sharps containers, like so many of our other infection control supplies in dentistry, some states have had to make exceptions to that because people could not get replacement sharps containers during that period of time. So it's all about documentation. So when you ship or your sharps containers are picked up, you sign a manifest. And a lot of people just sign it blindly, they don't really understand what it is they're signing. What you're doing is saying that you have packaged all of the contents that you're disposing of according to your state and federal regulations, and that you're responsible for how they're packaged when you give them to that service. The other piece of really critical documentation that you need is you need to get back from the sterile the sharps disposal service that you use, documentation of when and how those sharps containers were destroyed. Because the federal EPA rules say that we are responsible as generators of medical waste from cradle to grave. So from the time that waste is generated, I use my needle for an injection of local anesthetic all the way till that needle goes to the sharps container, to the waste company, and gets incinerated. So your waste company must give you back at some point some documentation of when and how your containers were disposed of. So if something goes wrong, then you have documentation that you did the right thing and it goes on the waste hauler or the waste company if they did something incorrect and you're not liable for it.
SPEAKER_03Thank you, Mary. And I appreciate the emphasis on the different ways to dispose of it and how important it is to verify state and local rules. You know, anytime a client of ours deviates from common practice of waste pickup, we highly suggest this be incorporated into their. Waste management plan so there's no uh discrepancies in the program, particularly if they've made special arrangements that we have all of that clearly documented in their plans. And I believe all of us probably have examples to share. And before we get into those violations that we've seen, Linda, can you share additional information?
SPEAKER_02In Florida, just to talk about a specific state guideline, we have our state biomedical waste rule that is in some ways more stringent than the federal laws. And it does talk about the time frame for removal of a sharps container from your practice. It is a different 30-day clock than the red bags. So, for example, if you have a sharps container sitting in an operatory you don't use very often, say for emergencies or a delhygiene operatory, that sharps container can be in place for more than 30 days. And then as soon as it's closed, then you have 30 days to get that off-premises. Whereas a sharps, the 30-day clock for a red bag starts the minute that you put your first pair of gloves or contaminated waste in that red bag. So every practice in Florida has a biomedical waste pickup company coming for the most part. Most most don't use the mailbag service, at least our clients, and they come every 28 days. So it's very specific on that guideline. And also our documentation in Florida has to be kept for three years. So we always make sure, and we have state inspections on this particular topic. So many times over, Florida practices will be confused and call and say, OSHA was just here, and they told us we we don't have our training or something along those lines. And then as I ask more questions, I realize the inspector was only there 20 minutes. They did, they weren't, you know, OSHA would be there probably an entire day. And you start asking all those questions, you realize it was just the state biomedical waste inspection. Um, so that's important to know. And I also wanted to mention, Olivia, that of all the things that we're talking about today, you know, if a practice is inspected and is found to be deficient in this area, this could be considered a willful violation. And if that's the case, then the average $13,653 fine per OSHA could be manifested tenfold and be a $136,000 fine for willful violations. So this is a great podcast and a great message for our listeners, Sylvia.
SPEAKER_03Thank you, Linda. That's so that's so helpful. And we all have situations we've run into as consultants. I remember some years back, I was doing a mock inspection in an office. And when I came through the sterilization area, there was a square style sharps container setting on the floor. And obviously, I had concern because it could be kicked over. And so I asked one of the assistants, well, what happens if everybody's busy and you come flying through this area, this hallway, and you accidentally kick the sharps container, what happens then? And she was very honest in her response. And she said, Well, that has happened. And I get my gloves and I pick up all the sharps and the needles and I put them back into the container. And I'm like, Thank you for sharing that. And so that's what would happen if I had been an OSHA inspector conducting a walk around and I interviewed a staff member, that would have been valuable feedback for OSHA to know that that was highly hazardous that could cause danger and injuries to the employees. And another example I ran into is ortho office, where there was so much orthodontic wire poking out of the opening that uh I listed it, of course, as a violation because it was too full. So we must recognize the fact of not exceeding the fill line. And if there's not a fill line to make sure we're not exceeding the container to cause a hazard to someone that's closing up the container. So, what other examples? Mary, can you share an example with us?
SPEAKER_01Absolutely. And in some practices where they maybe don't disassemble their syringes and so don't dispose of a lot of needles, they'll have smaller sharps containers in the treatment rooms and then a larger one perhaps in the sterilization area. And a common practice that I have seen in the past has been practices taking the small sharps containers, opening them up, putting the contents in the big container so that they can reuse those small containers. And that is not allowed. You never open up a sharps container. Um, once you've started using it, you never go in and you never remove the contents out of it. So don't try to save money by reusing the small ones unless you have a problem with the shortage of sharps containers right now.
SPEAKER_03Thank you, Mary. Leslie, what can you share with us?
SPEAKER_00Well, uh, just to piggyback on what Mary was talking about, we actually had a dentist in Northern California where his team was trying to save money. Of course, everybody wanted to meet their production goals and there was a bonus at the other end. And, you know, part of that was making sure that they uh towed the line on expenses. And so uh they were doing exactly that. And they thought they were doing the practice a favor, but then they had an OSHA audit, ended up that their fine was uh $25,000 for uh moving sharps from that one container into the larger container. And you know, doctor absolutely had no idea and when he expressed his concerns to the OSHA inspector, the OSHA inspector said, look, number one, you're supposed to train your team on blood-borne pathogens, and that includes handling sharps. And number two, you're supposed to train them on sharps container, and number three, this is your roof, and everything that happens under your roof is your responsibility. So you need to know. Now, in another case where we had uh a sharps container, uh, to what Olivia was saying about the fill line, um, there was it was sort of an unusual series of events. A hygienist got hurt. Uh, it was her operator stool that was faulty. And I'm sure we've all come across every now and then where dental equipment just gets used until it literally falls apart. Well, this was the case, and her operator's stools fell apart with her in it. Uh, she suffered a back injury. Um, OSHA was contacted, and when the OSHA auditor came to the dental practice, uh, they had already replaced the operator's stool. So there was no concern there. But he saw a sharps container that was over the fill line. And he fined the dentist $8,000 for that overfilled sharps container.
SPEAKER_03Wow, Leslie, thank you. I had another experience that was memorable. Some years back, a dental practice reached out to us because they had OSHA violations and they asked us to assist them, which we did. And because I was working closely with OSHA, we corresponded back and forth and I let them know that everything had been completed. And the OSHA official asked if we had made it up to the attic. And I said, Well, um, we usually don't go up in the attic as compliance consultants. And he said, Well, we'd like you to go back to that office and go up into the attic. I'm like, okay. And so one of our consultants went back out to that dental office and up into the attic. And there were years and years and years of sharps containers that were stored in the attic. So we had to make special arrangements to pick up all of these sharps containers. And evidently it came with the buildings. When the dentist purchased the practice, uh, that was like an added feature, having years of sharps containers stored up in the attic. So we we do need to look at these little corners and um storage areas that we may might not necessarily review to make sure it's all safe and orderly. Linda, what can you share with us?
SPEAKER_02That sort of makes you chuckle a little bit, Olivia. And I could say that we had a similar experience for an office in New York, only their extra sharps were in the basement. So we come across this from time to time in places that you don't think to look. And therefore asking good questions and sort of um, you know, being open and non-judgmental to this with the staff, you can elicit all kinds of information. So we normally wouldn't have gone to the basement either, but I believe in this case that might have been where the washer and dryer was. So we do inspect the safety of, you know, getting down those steps and getting up and everything. And that's where we found those sharps containers.
SPEAKER_03All right. The basements can be a source of lots of violations. So true, Linda. Mary, what can you share with us?
SPEAKER_01Well, we all have a similar story about that. I saw the same thing happen. There was a basement full of milk jugs, gallon milk jugs with um needles saved over the years that came with the sale of the practice. So when I know that someone is buying a practice, those are the things I now coach them on. Make sure you look in an attic, in a basement, in the farthest corners of the cupboards in the instrument processing area or storage area, because this particular practice also found multiple bottles of free mercury back from the days of mixing powder or pellets and mercury for umalgams, not in pre-measured capsules. So that's another whole disposal issue. And one of the things that I didn't mention in terms of disposing of sharps containers, some folks are allowed by some state regulations to take some type of a solidifier and put it in a sharps container so that the sharps can't be separated out. And then they can either take them to a landfill or some states still allow that to be put in the regular trash. But it's not something that I don't think any of us would recommend because the we don't know that those containers aren't completely rupture-proof and that you couldn't get the sharps out of it, but it is allowed in some states. So if that's what you're doing, then you need to make sure it is allowed by the EPA in your state.
SPEAKER_03Yeah, thanks for your insight, Mary. Leslie, what can you share with us?
SPEAKER_00I recall in the old days, and I mean, you know, prior to the bloodborne pathogen standard, we would sometimes take uh containers like milk containers or uh oftentimes alginate cans and uh put sharps in there and then fill them up with stone. And so I would encourage again anybody that's doing that, uh, you've got to make sure that that is something that would fly in your state or in your county, even you may have county restrictions on what kind of sharps containers can be placed into their landfill.
SPEAKER_03Great information. This has actually been a very informative episode about sharps containers. So thank you, fellow Divas. We bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please submit your questions about Sharps disposal to support at the compliancedevas.com. We will place the resources that we talk about during this episode on our website. Please tune in next time. Thank you for allowing me to be your moderator. See you again.