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Journal of Hospital Infection (1990) 15, 287-294

INFECTION CONTROL IN PRACTICE

Sharps disposal containers and their use

J. Gwyther

Division of Hospital Infection, Central Public Health Laboratory, Colindale,


London

Accepted for publication 18 December 1989

Summary: Safe disposal of sharps in health care is more important than ever
before especially with the risks of disease transmission. This paper reviews
the fundamental issues of sharps containers including design features,
container use and the future needs for safety. A simple solution meeting all
requirements may never be available and further research to strive for the
safest design is still needed. Although an ultimate design may emerge, the
general education of all sharps users regarding safety will always be para-
mount.

Keywords: Sharps containers; sharps disposal

Introduction
Improved design and construction of sharps disposal containers has
followed increasing interest in occupational safety. Recognition of the
possibility that sharp instruments may transmit hepatitis B virus (HBV) and
human immunodeficiency virus (HIV) led to demands by users for more
and better safety features in sharps containers. Manufacturers have met this
demand with enthusiasm, producing containers in all shapes and sizes and
claiming a variety of safety features. This review is intended to place these
features in context, bearing in mind the requirement to protect staff during
all stages of sharps disposal, up to and including the incinerator operator.
The present generation of sharps containers are much superior to those of
a decade or so ago, but the one fundamental problem affecting them all is
persuading staff to put used sharps in the containers.

Sharps container specification


The Department of Health (DoH) p ro d uced a specification for containers

Address for correspondence: 2 Willow Grove, South Woodham Ferrers, Essex, CM3 5RA.

0195~6701,90,030287+08 s03.00/0 Q ,990 The Hospital Infectmn so.xty


287
288 J. Gwyther

for sharps disposal in 1982 and a list of containers which comply with these
specifications can be obtained. The manufacturer of the product submits a
sample for visual examination and limited testing. There is no formal
product approval scheme. A British Standards committee has recently been
set up to translate the DoH document into a British Standard which should
be available by 1990.* Until then the 1982 document still applies and
consists of nine requirement categories for containers related to their design
(Table I).

Table I. Summary of Department of Health specifications

1. Syringe and needle should be discarded as one unit; container must not have a
device to facilitate needle removal.
2. The aperture will inhibit contents removal.
3. A single-handed operation should be used to discard items with minimal external
surface contamination.
4. Secure closure must be possible.
5. No visible signs of leakage will be shown: container will hold water, 10% of its
volume, at 15 & 5°C for 24 h.
6. The container shall resist penetration: filled with 1 ml syringe and attached
0.5 mm x 16 mm (orange) needles, dropped from a height of 1 m with no visible
penetration.
Container material can be incinerated.
;: Background colour shall be yellow.
9. Labelling shall include ‘Danger’, ‘Contaminated Sharps’, ‘Destroy by Incineration’
or ‘To be Incinerated’.

Design features
Each container approved by the DoH for sharps disposal should have
standard features complying with the specification. However, the design of
these features can vary considerably and may affect the popularity of a
certain product.

Material
The container is required to meet satisfactory levels of resistance to leakage
and penetration in accordance with the tests (see Table I). Of the containers
available, some brands are made of polypropylene or plastic and others are
cardboard based. The polypropylene products are similar; the cardboard
varieties are presented as either corrugated board, some with ‘fluid-proof
coating, or as a drum with a ‘moisture-resistant’ coating.
Fluid leakage has not been recorded as a problem with any polypropylene
or plastic designs and most cardboard ones have a coating to resist leakage.
Problems may arise however if used cardboard containers are left exposed to
wet weather conditions within hospital grounds before ultimate disposal.

*A draft British Standard was recently distributed for comment.


Sharps disposal containers 289

The use of yellow plastic bags to enclose used containers is recommended


by the Health and Safety Commission (1982).
None of the containers are claimed to be ‘puncture-proof’. Weinstein
(1985) states that ‘puncture-resistancy’ varies, due to different coatings in
cardboard designs and the fact that plastic designs manufactured by a
moulding technique can have different resistance at different sites in the
container. When in use with a whole range of sharp objects, not only needles
as in test 6, sharps accidents have occurred following container penetration.
Krasinksi, LaCouture & Holzman (1987) showed that changing from a
cardboard box to a plastic one resulted in a fall of container related injuries
from 1.3 to 0.3 needlesticks per month. Ribner et al. (1987) described a
similar result, finding that changing from cardboard to plastic containers
reduced disposal related injuries from 0.9 to 0.3 per 100 full-time employees
per year. This illustrates how the container material may determine related
injury rates. A mixture of sharps would be a more exacting test load for
container penetration than a single type of sharp.
The container must be disposable by incineration. Production of toxic
gases and smoke during incineration may cause problems especially with
polypropylene or plastic designs, though most manufacturers claim that
their product does not emit toxic fumes. Incinerator efficiency and
maintenance will determine the ability to cope with these problems.

Aperture
The aperture design must comply with specifications 2, 3 and 4 (Table I).
These requirements are difficult to meet when the user also requests that the
container accommodates a range of sharps from a needle to a whole infusion
set. Only a few infusion sets would be needed to fill a container which would
be uneconomical, yet spike penetration of plastic disposal bags is a definite
risk.
Some manufacturers produce a single aperture design with one or two
sizes to fit their range of containers. Others alter the aperture design to suit
the container size. The range then provided is more versatile and finds use
in a wider selection of locations from community to wards and theatres. The
aperture size may be the determinant for user acceptance. Conflict lies
between the ability to remove contents and the larger sized aperture. A
sensible decision will compare the safety factors with the convenience of
aperture sizes. For instance, theatres need to dispose of large quantities of
sharps quickly and size is beneficial; a paediatric ward with children’s
exploring hands and smaller sized sharps will favour safe, smaller apertures.
Some containers have an inner flap at the aperture which relates to
specifications 2 and 3; other apertures remain open during use. If left open,
the contents may spill when a container is accidentally tipped. Conversely,
any flap requiring two hands for use contradicts specification 3. To
overcome the risk of spillage most containers can be closed intermittently;
however the frequency of this practice is questionable. If containers were
290 J. Gwyther

secured by a wall bracket or floor stand the risk of spillage would be reduced
and the aperture could remain open.
Over-filling containers also relates to the aperture design. This problem is
mainly due to human error and negligence. Inner flaps at the aperture may
impede over-filling, but the majority of containers are vulnerable to this
misuse. Moir-Bussy (1982) reports an instance where a container came
apart, possibly due to over-filling, and the contents were spilt. User
education could be the most appropriate solution, accompanied by an
efficient changing system for used containers.

Lid
Some containers have a lid incorporated into the top surface; others have a
detachable lid which may or may not be secured to another site on the
container. Any lid that requires a certain degree of downwards force to
ensure security can be extremely dangerous. The user could be injured from
penetration of the container by sharps located close to the opening.

Assembly
Some cardboard designs are delivered flat and require skill and time for
assembly. Buckles (1980) assessed three cardboard assembly types finding
only one to be ‘relatively easy’. Most polypropylene or plastic containers
consist of two separate parts which must be carefully aligned and connected
with a degree of force. The cardboard drum designs are supplied fully
assembled. Ease of assembly is imperative; a small error margin may result
in a dangerous, wrongly assembled container. Time is valuable in a busy
department, so fully assembled containers are the ideal, but this often
conflicts with lack of storage space. The simplest two-piece design may be
the solution.

Carriage
Inadequate carrying handles will lead to the practice of carrying the
container close to the body, exposing the person to possible injury from
sharps which have penetrated the container. The handle design of
polypropylene or plastic and cardboard containers vary. Some do not have
handles; others have flimsy ones which can be difficult for a porter, wearing
thick gloves, to carry. Other designs have a strong metal handle similar to
that of a bucket. Some have handles as part of the lid mould. A reasonably
sturdy handle appears to be a useful safety feature.

Label&g and colour


The background colour of the walls of the container must be yellow. All
products meet this requirement, as they do with labelling which must
include the words as stated in specification 9.

Size and shape


Container size must satisfy a compromise between portability and volume.
Sharps disposal containers 291

For example, a community nurse will give occasional injections and remove
sutures so a small container will suffice. Hansford (1979) surveyed
containers available in a hospital and concluded that no single container can
meet the full range of requirements, from the heavy demands of intensive
care to the smaller needs of outpatient departments. The range of sizes now
available is vast, from 325 ml to 23.2 1 and caters for the majority of
demands. Standardization of sizes would be useful. At present size is
expressed in litres and gallons, making comparison of unit costs difficult.
The dimensions of a container will influence the type of sharps which it
will accept, for example a 20 ml syringe with attached needle will not fit into
a l/2 gallon drum container. This can lead to the ill-advised practice of
detaching the needle from the syringe which may result in a needlestick
injury. Tall, cylindrical or square containers may accommodate long, thin
sharp items, but space will be wasted if items criss-cross inside leaving
unfilled gaps in between. Diagonally positioned sharps may result in
container penetration when a further load of sharps is placed on top. A
much larger diameter will allow its contents to settle in a horizontal
position, taking up less space.

Sharps container use

Establishments which use sharps disposal containers will have to consider


factors not directly related to use such as cost, disposal facilities and storage.

cost
Hospitals place economy as a high priority and equipment is frequently
purchased on this basis (Moir-Bussy, 1982). In the case of sharps
containers, safety should be a higher priority. Generally the cardboard
containers are cheaper than equivalent sized polypropylene or plastic,
although the difference narrows with increased volume, so that the price
difference becomes minimal. Larger containers are cheaper per unit volume
than smaller ones, but certain departments may have a low turnover of
sharp items or limited space so a larger container would not be suitable.
There is concern at the distance travelled to a container. If a small
container existed in several locations, i.e. at each bedside, disposal could be
immediate reducing the problem of misplaced sharps and non-user injury.
There is a report of a 53 % reduction in the number of needlestick injuries as
a result of the installation of disposal containers in each patient’s room in an
American hospital (Anonymous, 1988).
Cost relates to the usable space within each container. One manufacturer
claims that the size and shape of their containers make them more
economical as needles and syringes can lie flat. This is possible when
compared with containers that have a small diameter where a syringe-needle
combination will lie diagonally. Cost will be a strong influence on
purchasing, but it must be carefully balanced against the establishment’s
safety needs.
292 J. Gwyther

Disposal facilities
All used sharps containers require incineration. It is critical for each
establishment to examine the impact that containers will have on the waste
disposal system (Weinstein, 1985). The facilities for incineration vary over
the country. The age of the incinerator itself will influence container choice;
cardboard is obviously easier to destroy. Careful management of disposal is
imperative and if facilities for disposal are poor or inadequate there are
companies who will collect and dispose of used containers. This service is
ideal for dentists and general practitioners (Griffiths, 1983). Careful mixing
of waste for incineration to intersperse plastics with other materials which
are more combustible, may aid adequate incineration.

Storage
Collins & Kennedy (1987) stress that any complaints that containers are
expensive and create problems should be disregarded. There are certainly
other factors that should take priority over these matters.
Storage will depend upon the container design as to whether it stacks as
two pieces, lies flat or remains whole. New Regional stores arrangements
where supply and demand are strictly controlled so that supplies arrive on a
monthly or other regular basis will ease storage problems. At ward level
storage space is often lacking. Careful hospital-based management of
container distributior should mean that container choice and availability
will not be affected.

Future needs
With any device used n the clinical setting it is important to anticipate how
needs will change. Since 1982 when the DoH specification was produced
there have been design changes, for example, to provide for smaller
containers in the community and larger ones in theatres. What for the future
now?

Security
Concern about security has led to wall brackets to hold the container and to
facilities for padlocks, since the theft of containers and the sale of contents is
a problem. In some American hospitals containers in individual patients’
rooms are locked into position. Wall brackets are also useful space savers
and containers can be locked at a convenient height. Further security is
obtained by making the contents inaccessible. Some containers cannot be
separated into two parts and have aperture sealing mechanisms which are
extremely difficult to reopen. Any extra security adaptation will increase
cost, and manufacturers need to keep costs as low as possible.

Flexibility of design
Containers with different features are needed for different clinical areas.
Sharps disposal containers 293

Manufacturers in collaboration with users can devise appropriate designs to


produce a flexible range of products. In-service training is advantageous but
at present only one manufacturer supplies this.

In-use assessment
Relating reported sharps injuries to different designs of containers provides
an assessment of their suitability.
Evaluating the container by questionnaire completion by the user is
another tool for assessment. Ideally a standard evaluation schedule should
be devised involving technical analysis, quantitative assessment and
subjective data to determine the most suitable design for a particular
situation.

Conclusion
There is no single container design which meets all needs and it seems there
may never be. There are still areas where improvements can be made, for
example, the aperture design, carrying handles and two-piece assembly
joints. Further communication between container users and manufacturers
to discuss new designs, specific features and criticism could be productive.
Health care workers need to express their concern for safety, especially
when selecting products for clinical use, and demand high standards.
It is unwise to supply sophisticated equipment such as vacuumed blood
collecting systems and sharps containers if they are not used correctly and
effectively. A material item cannot be expected to be foolproof and sharps
disposal involves a high degree of human interaction. Krasinski et al. (1987)
believe that an individual’s behaviour is an important determinant of
needlestick injury. They found that the overall total of needlestick injuries
remained constant, regardless of a fall in container-related injuries, when
the sharps container was modified.
There needs to be a selection of containers to suit different situations.
Varying container size is not the only solution: the shape, aperture design
and carrying handles all need to be accommodating. In the ward, bedside
containers would enable immediate disposal of sharps and avoid carrying
sharps over a distance (Wormser, Joline & Duncanson, 1984).
Sharps disposal containers are only a small part of a more complex
interplay of factors leading to accidental sharps injury. Jagger & Pearson
(1987) explain that a sizeable reduction of accidents will require more
understanding of the many causal features; there is a need to promote
further scientific inquiry into each facet of sharps accidents.

References
Anonymous (1988). In-room sharps disposal systems reducing needlesticks. Hospital
Infection Control 15, 85-88.
294 J. Gwyther

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Collins, C. H. & Kennedy, D. A. (1987). Microbiological hazards of occupational needlestick
and sharps injuries. Journal of Applied Bacteriology 62, 385-402.
Department of Health (1982). Specification for Containers for the Disposal of used Needles
and Sharp Instruments. Specification no. TSS/S/330.015.
Griffiths, G. (1983). What a waste! Nursing Times, 3 August, 8-9
Hansford, J. (1979). Sharps and their disposal. Sterile World 1, 5-6.
Health and Safety Commission (1982). Th e safe disposal of clinical waste. H.M.S.O.
Jagger, J. & Pearson, R. D. (1987). A view from the cutting edge. Infection Control 8, 51-52.
Krasinksi, J. K., LaCouture, R. & Holzman, R. S. (1987). Effect of changing needle disposal
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Moir-Bussy, B. (1982). Sharps and their safe disposal. Journal of Infection Control Nursing
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Ribner, B. S., Landry, M. N., Gholson, G. L. & Linden, L. A. (1987). Impact of rigid,
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