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/policies/clinical/uw-health-clinical/infection-control/4110.policy

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UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Infection Control

Sharps Disposal (4.1.10)

Sharps Disposal (4.1.10) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.10


UW HEALTH CLINICAL POLICY 1
Policy Title: Sharps Disposal
Policy Number: 4.1.10
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: April 14, 2017

I. PURPOSE

To reduce the risk of percutaneous injuries in UW Health settings (inpatient, clinic, outpatient, home health)
by mandating prompt disposal of used needles, scalpel blades, razors, syringes, broken glass, or other
medically-related sharp items in designated disposal containers at the point of use.

II. POLICY ELEMENTS

A. It is the responsibility of the person using the sharp device to immediately activate the safety feature of the
device if it is of a design requiring such a step, and to then immediately dispose of the device in the
appropriate impervious container, or make arrangements for the safe disposal of the sharp device.
Employees will not dispose or leave used sharp devices in areas that place employees, patients, students,
or visitors at risk of injury (e.g., patient bed, procedure tray, regular trash).
B. Used needles, syringes, scalpel blades, and other disposable sharp items will be disposed of immediately
after use into impervious sharps disposal units. Refer to UWHC policy #8.89, Preventing Non-therapeutic
Exposure to Hazardous Drugs and UWMF policy, Preventing Occupational Exposure to Hazardous Drugs
for information regarding safe handling and the disposal of sharps devices used in the administration of
chemotherapeutic agents.
C. Sharps disposal containers (e.g., red biohazardous sharp containers, white or yellow chemotherapy sharp
containers, large red bins) will be widely and continually available in locations that facilitate their immediate
use (e.g., patient rooms, treatment rooms, and laboratory).
D. Sharps disposal containers should be mounted on a wall at the National Institute of Occupational Safety &
Health (NIOSH) recommended height whenever possible (container opening 52-56 inches from floor).
Containers must be mounted as close to the point of use as possible in a readily accessible location, free of
obstructing items.
i. Containers must not be mounted in a location in which they are recessed, such that disposal of an
item requires the individual to open a door or to reach into a limiting space in order to access the
opening of the disposal container.
ii. Whenever feasible, the opening of the disposal container should be clear on all sides for a distance
of at least 8 inches so that healthcare workers can approach the opening from any direction to
dispose of sharp items without impedance, and so that Environmental Services personnel can
remove filled containers without excessive tilting or manipulation of the container to avoid nearby
objects.
iii. When the wall mounting of a sharps disposal container is not possible due to room or functional
layout, a mechanism such as counter-top brackets or fitting the container into a base should be
considered to prevent the container from falling over if it is in an area where this is likely to occur.
Portable containers should be stored at 38-42 inches from floor; not within easy reach of children.
iv. Sharp containers will have the lid securely attached prior to being put into active use. It is not
acceptable to add the lid after the container has begun to be filled as this extra manipulation may
result in a spill of contents or inadvertent extension of hands or digits into the in-use container.
a. For disposal of large or odd shaped sharp items, containers with larger openings in the lid
may be considered. Alternatively, such items may be discarded into the large red
impervious biohazard bin.
v. Consideration will be made as to the design and placement of containers so that tampering by
patients or visitors may not readily occur.
E. Shearing or breaking of contaminated sharps is prohibited. Recapping of contaminated needles is prohibited
except when unusual circumstances do not permit immediate disposal. If recapping is unavoidable, a
mechanical device (e.g., hemostat) or one-handed method of recapping must be used to minimize risk of
injury, and care should always be taken to observe that the needle has not pierced through the cap.
F. Filled sharp containers will be replaced promptly. Containers should be removed when the contents reach
the “fill line” delineated on the container by the manufacturer; if no fill line is indicated, they should be
removed when 3/4 filled.
G. UW Health encourages outpatients to safely dispose of sharps generated in their home environment.
Specific UW Health locations serve as collection sites for properly packaged and labeled sharps generated



UW HEALTH CLINICAL POLICY 2
Policy Title: Sharps Disposal
Policy Number: 4.1.10

in the home environment. Procedures for proper disposal of household sharps are covered in section IV
below.
H. The Environmental Services Department will consult with and involve the Infection Control Department in the
evaluation and purchase of new designs of sharps disposal containers.

III. PROCEDURE FOR SHARPS DISPOSAL AT UW HEALTH
A. Discard syringes (with needle attached), scalpel blades or other sharp items directly into the designated
sharps container at the point of use. Used needles are not to be recapped, bent or broken. Needles are not
to be detached from used syringes or phlebotomy devices prior to disposal. Sharps disposal containers are
not to be filled beyond the manufacturer’s indicated fill line, or more than 3/4 full if no such line is indicated
by the container manufacturer.
B. An empty syringe without a needle attached can be discarded into the regular trash receptacle unless it
contains significant amounts of blood or body fluids, in which case it should be discarded into a sharps
container or red bag. Consideration for disposal of items containing residual drugs can be found in UWHC
policy #8.89, Preventing Non-therapeutic Exposure to Hazardous Drugs and UWMF policy, Preventing
Occupational Exposure to Hazardous Drugs.
C. Return non-disposable needles (e.g., specialty, bone marrow, liver biopsy) and reusable glass syringes to
designated trays and place in the a tray labeled with a biohazard symbol in the soiled section of the nurse
server or take to the ACCO area for return to Central Supply.
D. Large sharp devices such as used chest tube trocars should be returned to their original impervious
containers at the point of use and discarded in a large sharps container as they will not safely fit in sharps
containers typically found in patient rooms.
E. In the event that a sharp container is approaching the fill line or is found to be overfilled, it must be replaced.
F. Sharp injuries must be reported to Employee Health Service (or the UH or The American Center Emergency
Department when Employee Health Service is closed, or to local Urgent Care Clinics for ambulatory
locations distant from UH or The American Center) as soon as possible as described in UWHC policy #9.28,
Management of Biohazardous Injuries.

IV. PROCEDURE FOR ACCEPTING SHARPS GENERATED IN THE HOME ENVIRONMENT FOR
DISPOSAL

A. In order to be acceptable for disposal through UW Health locations, used needles, lancets, and other
medically-related sharps generated in the household environment will be disposed of in commercially
available sharps disposal containers or hard plastic liquid laundry detergent bottles appropriately labeled
with a biohazard sticker.
i. Commercially available sharps disposal containers are available for purchase in many UW Health
Clinics, UW Health Pharmacies and through UW Health Home Care Services.
B. In the household environment, an acceptable alternative to a commercial sharps disposal container is an
empty, heavy gauge plastic liquid laundry detergent bottle with its screw-on cap. Outpatients choosing to
use plastic laundry detergent bottles will be provided with an adhesive biohazard label to affix to the bottle,
and also a copy of UW Health Facts for You #4587, Safe Sharps Disposal at Home which provides
instruction for proper labeling and disposal.
i. Adhesive biohazard labels and Health Facts for You #4587 are available at the University Hospital
Outpatient Pharmacy and through UW Health Home Care Services. The biohazard label must be
affixed to the detergent bottle to be acceptable for disposal at UW Health locations.
C. When the sharps container is full (waste volume reaches the full indicator line on a commercial container, or
when the hard detergent bottle is roughly 3/4 full), the patient will close the container or detergent bottle as
instructed in Health Facts for You #4587 and return it to the University Hospital Outpatient Laboratory, a UW
Health Pharmacy, or other UW Health locations designated as collection points for appropriately packaged
sharps. Appropriately packaged sharps can also be given to the UW Health Home Care Services healthcare
provider during a home visit.
D. The returned sharps containers and properly labeled detergent bottles will be disposed of in the appropriate
waste stream in accordance with organizational waste management plans.

V. FORMS

Health Facts For You #4587, “Disposal of Sharp Wastes at Home.”
Biohazard Sticker



UW HEALTH CLINICAL POLICY 3
Policy Title: Sharps Disposal
Policy Number: 4.1.10


VI. COORDINATION

Author: Infection Control Practitioner
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: none
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: March 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

UWHC policy #9.28, Management of Biohazardous Injuries
UW Health Bloodborne Pathogens Exposure Control Plan
Blood or Body Fluid Exposure resource page on the Employee Health U-Connect site (includes UWMF
resources)
UWHC policy #8.89, Preventing Non-therapeutic Exposure to Hazardous Drugs
UWMF policy, Preventing Occupational Exposure to Hazardous Drugs.
HFFY# 4587, Safe Sharps Disposal at Home
UWHC Hazardous Material and Waste Management Plan
UWMF Hazardous Material and Waste – Medical Waste Management resources on U-Connect

Occupational Safety and Health Administration: 29 CFR Part 1910.1030 Occupational Exposure to
Bloodborne Pathogens; Final Rule, December 6, 1991; revised January 18, 2001

Wisconsin Department of Natural Resources Publication PUB WA-1636-2013, “Protect Yourself, Protect
Your Community.” Available at: http://dnr.wi.gov/files/PDF/pubs/wa/WA1636.pdf

Wisconsin Department of Natural Resources Bureau of Waste and Materials Management. List of
Registered Sharps Collection Facilities, available at:
http://dnr.wi.gov/topic/Waste/documents/faclists/SharpsCollection.pdf

IX. REVIEW DETAILS
Version: Revision
Last Reviewed: April 14, 2017
Next Revision Due: April 2020
Formerly Known as: Hospital Administrative policy #13.09