Proper sharps handling both during use and disposal can prevent injury and cross-contamination.
Burs, needles, and other sharp objects are commonplace in the dental practice. They are so pervasive that they can be taken for granted. However, they carry with them the real risk of hazards.
In 2013, a New Jersey patient experienced, first-hand, just how life-changing a sharps injury can be. During a routine root canal, the needle that had previously been used to inject Novocain into her mouth was accidentally dropped into her eye (her dentist failed to provide eye protection).1 The resulting infection caused her to lose her eye.1
This is an extreme example, but it underscores just how dangerous sharps injuries can be and the necessity for proper handling both during use and disposal.
It all starts with safely handling sharps, for the protection of both team members and patients.
“Before I ever pick up an instrument, I make sure my patient has safety glasses on,” says Douglas Risk, DDS, ABGD, FICD, a compliance manager and private practitioner at Tidewater Dental, which has several offices in southern Maryland, and member of the Executive Board of Directors for Organization for Safety, Asepsis, Prevention (OSAP). “Safety is number one for the patient, because they don’t have a choice whether they’re going to be participant in a sharps injury. Very often, they don’t have much control. Someone is handling that sharp and it’s coming close to their face. So, for that reason, sharps safety for the patient is first.”
Sharps safety for the provider team is second, Dr Risk says, because they’re the ones handling the sharp objects and the ones who can cause injuries by being careless.Sharps safety, largely, comes down to the clinician’s technique.
“Most of it, in my experience, would be based on technique,” Dr Risk says. “What is the patient exposed to? How are they exposed and what are the things that you do to mitigate that?
“Sometimes…the tongue just wants to batter your handpiece all over the place, and so that’s kind of a problem,” Dr Risk continues. “But that’s all technique and there are instruments that can help. There are silicone isolation devices, like the DryShield or IsoDry by Zyris. The heavy rubber dam is my favorite, and that does a pretty good job of protecting the cheek and the tongue, although the patient can still push that.”
Once a sharp has been used, it must be safely contained before disposal. The Centers for Disease Control and Prevention (CDC) guidelines recommend that sharps containers be mounted on the wall, according to Jonathan Rudin, DDS, MS, MPH, the safety and infection control consultant at San Diego Healthcare Compliance in San Diego California. These containers should be placed at specific heights from the floor to the opening; if they are too high, it is dangerous to dispose of sharps; if too low, patients or children can access the container, Dr Rudin adds.
“The sweet spot for positioning the sharps container is that they be low enough to allow easy disposal of contaminated sharps and high enough to prevent children from accessing it, in accordance with CDC recommendations,” he says.
The CDC recommends placing a sharps container in each operatory. This eliminates unneeded handling of contaminated sharps, such as transportation to a centralized disposal location.
“Ultimately only instruments designated for sterilization would be transported to the sterilization area. All trash and disposable contaminated sharps should be discarded in the operatory,” Dr Rudin explains.
However, the containers aren’t, in and of themselves, enough to do the job. They must must be used properly, including emptying the container when the fill line is reached.
“Once a sharps container’s fill line is reached, it should be disposed of according to manufacturer’s instructions and in conjunction with local biohazardous waste disposal requirements,” Dr Rudin says. “I’ve heard that OSHA and health department inspectors will look for overfilled sharps containers, so I always caution my clients to be sure the fill line is not exceeded. The purpose of the fill line is to avoid sharp injuries during the discarding process.”
It would be easy for a person to discard a sharp to be injuried if the containers are filled past that line. This is why the fill line is printed significantly below the sharps container opening, according to Dr Rudin.
Once the operatories’ sharps receptacles are filled, practices must ensure that its contents are disposed of properly. Dr Rudin lists 3 main biohazardous waste disposal methods:
As ubiquitous as sharps are, there are still plenty of common mistakes being made when it comes to handling and disposal. Ensuring proper needle coverage, for example, is key, Dr Risk says.
“Some providers don’t rigidly cap the needles, they just cover the needle,” he says. “And when an assistant picks up the anesthetic arrangement, the cap will fall off. I always make sure my needle is secure, but some people just don’t secure it.”
Proper storage of full sharps containers is also important, as they are considered biohazardous and can cross contaminate supplies and PPE, Dr Rudin explains.
“I often see filled sharps containers that are awaiting pickup being placed in the same closet where patient care items are stored,” he says. Sharps containers should be placed in their own dedicated area that’s kept under lock and key. Doing so will eliminate the chance of patient care items becoming cross-contaminated and prevent access by unauthorized personnel.”
It is also important to remember that not all sharps are actually ‘sharp’, Dr Rudin adds. While some may think it is obvious what constitutes a sharp, it is actually more of a gray area, he says. Glass carpules and anesthetic cartridges are considered sharps and should be disposed of in the correct container.
“Remember that blood can be aspirated into a cartridge during the anesthesia procedure. If such a cartridge is then discarded into the regular trash, some action might cause that cartridge to shatter,” Dr Rudin says. “The resulting glass shards can easily perforate through a trash bag and into the leg of an unsuspecting staff member hauling the trash out to the dumpster.”
Reusable Sharp Instruments
Disposable sharps aren’t the only sources of hazard in the practice. There are many reusable instruments used in dentistry and dental hygiene that are sharp enough to puncture skin, scrape the arm or hand, and cause a contamination injury. These instruments must be handled with an equal amount of care as a needle or bur.
“Chairside, sharp instruments can inadvertently be passed incorrectly or fumbled, resulting in an instrument dropping from the hand,” Dr Risk says. “This is why instruments should never be passed over a patient’s face, and why protective eyewear is critical for the patient and the provider team, just in case an instrument is fumbled close to the patient’s or staff members’ eyes.”
When the procedure is completed, care must be taken for their transport, cleaning, and sterilization. The CDC recommends that instruments be transported in a leakproof, solid container with a lid that will not be opened easily if the container is dropped or bumped enroute, according to Dr Risk.
“Once contaminated, an instrument can be safely and gently wiped clean chairside facilitating decontamination in the central sterile area,” he says. “At the end of a procedure, since the reusable instruments are still contaminated, they must be transported with minimal risk to injure someone along the way.”
Once instruments are in the sterile area, they should be decontaminated with minimal touch, preferable with an automated system, such as an ultrasonic cleaner or washer-disinfector, Dr Risk adds.
“Instruments should then be inspected for damage, cleanliness and corrosion under magnification, packaged and sterilized according to CDC recommendations and the manufacturer’s instructions to ensure sterility of each instrument.”
If there is an accidental sharps injury, practices should refer to their office exposure plan, Dr Risk says. Each office may have different specific protocol, but the broad strokes are to get evaluated for bloodborne pathogens exposure, he says.
“A lot of times the person that was stuck—we call them the victim or the patient—would be tested for various bloodborne pathogens baseline, Dr Risk says. “Then, ideally you would do the source patient’s blood work, find out if they have any bloodborne pathogens circulating—like Hepatitis B or C, HIV—and then you would go from there and follow up with the victim/patient at certain intervals.”
A sharp puncturing intact skin is one of the avenues for microbes to enter the body, according to Dr Rudin. In this instance, the person should first wash the wound with soap and water, followed by filing a report with the staff safety officer.
“Third, the staff member should be sent to a facility like urgent care where blood testing will occur,’ Dr Rudin explains. “There’s optimally, a 2-hour window for getting that blood draw. That sample will be used to determine the staff member’s baseline level of infection. This test reflects the exposed’s status before the replication of any new microbes that entered due to the needle stick. Fourth, the exposed should ideally consult with an infectious disease specialist with current knowledge of diagnostic and treatment protocols for these kinds of infections.”
Any sharps injury, no matter how seemingly small, carries with it grave risks. But sharps injuries don’t have to be as frightening as a needle being dropped in a patient’s eye. With proper handling and disposal, team members can keep everyone safe.