Understanding the Components of a Written Infection Control Plan

This article is an edited transcript of a live webinar.  Please download the accompanying handout of the webinar slides.

Overview

During this course, we will review the written infection plan as required by the Occupational Safety and Health Administration (OSHA).  Why do we need to have a written infection control plan?  While hospital infection control procedures have always been in place, the discovery of HIV had a significant impact on how health care services were to be delivered moving forward.  This created a domino effect of policies and procedures that were implemented by a number of agencies and governing bodies, including OSHA and the Centers for Disease Control and Prevention (CDC), offering guidelines or regulations in the form of universal precautions, body substance isolation and now, the current standard precautions.  These policies and procedures were designed to minimize or eliminate the risk of exposure to potentially infectious agents. 

In 1983, when HIV was first discovered by researchers but not yet named, the CDC published a document that was called The CDC Guideline for Isolation Procedures in Hospitals. This document called for blood and bodily fluid precautions in those specific instances where a patient was either known or suspected to be infected with some type of blood borne disease.  About two years later, in 1985, as a direct response to the AIDS epidemic, the CDC expanded their original fluid and body precautions and specifically addressed the prevention of HIV transmission to health care workers.  In 1987, the CDC once again increased the scope of their guidelines recommending that blood and bodily fluid precautions be consistently applied to all patients in the health care environment, regardless of HIV or other blood borne status.  This approach is what became known as universal precautions. In that very same guideline, another set of rules referred to as a Body Substance Isolation, or BSI, were also introduced.  The BSI guidelines share many of the same features as universal precautions, with additional emphasis for health care workers to also avoid all bodily fluids, including what are considered moist bodily substances (e.g., urine).  This was done as an additional measure of controlling the potential spread of disease.  To maintain the most up‑to‑date isolation practices, the CDC revised their original guideline in 1991 to include two tiers of precautions to prevent transmission of infectious agents: standard precautions and the addition of transmission‑based precautions (in specific instances when somebody is known to be infected with some sort of airborne, blood borne or contact borne disease). 

Standard Precautions

Standard precautions combine all the elements of universal precautions with some key features of the BSI system.  Just like universal precautions, standard precautions are based on the mindset that all human blood and certain bodily substances are potentially infected with HIV, Hepatitis B or some other bloodborne pathogen.  Standard precautions also incorporate the elements of the body substance isolation system whereby all fluids and substances including moist substances are deemed potentially infectious.  Standard precautions also took it a step further to identify ubiquitous micro‑organisms readily found throughout the environment as also potentially infectious.  Standard precautions apply to the care of all patients regardless of the presumed or known diagnosis.  As such, every patient must be treated with the same basic level of established protocol designed to minimize the spread of disease. The required protocol involves these standard precautions:  appropriate personal barriers, hand hygiene, disinfecting touch and splash surfaces, sterilizing critical instruments and disposing of infectious waste. 

What do we need to do?  In order for disease to spread, a micro‑organism needs a mode and a route for disease transmission.  Mode refers to how an organism gets from one place to another.  The most common mode of transmission in the audiology clinic occurs either via direct contact where, for example, your bare hand comes in contact with a draining ear; as well as via indirect contact, where contaminated items are either handled with bare hands or they make contact with objects that are going to be used with other patients.  Once that happens, the a micro‑organism needs a route, or a portal of entry, into the body.  This includes dry skin as well as any of the natural body orifice including the nose, eyes, mouth and ears. Once a micro‑organism enters the body, a multitude of different things need to happen in order for disease to potentially manifest.  With infection control, our job is to consciously manage the clinical environment by specifically controlling the mode and the route of potential microbial transmission during the provision of audiological services. The best way to ensure this is done is by developing and implementing a written infection control plan as required by OSHA.

Written Infection Control Plan

There are six required sections of the infection control plan:

1. Employee exposure classification
2. Hepatitis B (HBV) vaccination plan
3. Plan for annual training and records
4. Plan for accidents and accidental exposure follow‑up
5. Implementation protocols
6. Post‑exposure plans and records

Your written infection control plan does not have to necessarily be in this exact order, but it must include these six required portions. 

Employee Exposure Classification

Each employee is going to be classified into one of three categories based on the employee’s potential of exposure to blood and other potentially infectious substances due to their job responsibilities. Category 1 employees are those whose primary job responsibilities expose them to blood and bodily fluids on a daily basis.  With regard to the audiology world, if you are involved in intra-operative monitoring, which puts you in the surgical suite as well as doing a significant number of post‑surgical audiological assessments, you will likely be classified as a category 1.  All other audiologists are going to fall under what is referred to as the employee classification category 2.  Individuals who have no part of their job responsibility that would expose them to blood or bodily fluids (e.g., audiologists involved only in administration who have no patient contact, as well as front office staff) would be categorized as category 3 employees. 

Categorization of Employees. The first section of your written infection control plan includes definitions that specifically define what each of these categories mean. I have a written infection control plan template that I can provide you if you are interested; this section can simply be copied word-for-word from the template because it provides the definitions of the categories that need to be included in your plan. 

Make a list of every person working in the office, whether they are audiologists or front office staff. Also, if you have students coming to your center, they need to be classified as well. Next, assign a category to each of the employees based on their potential for exposure to blood and other bodily substances. Again, the majority of audiologists or hearing instrument specialists will be category 2.  All students will be category 2.  Front office staff that do not make any physical contact with patients (other than greeting them and making appointments) would be categorized as 3.  In the back of your infection control plan you would have a form called the Exposure Classification Record Form which would be completed for every employee and kept on file, indicating what category they fall into based on their job responsibilities. 

Hepatitis B (HBV) Vaccination Plan

Any employee assigned to the classification category of 1 or 2 must be offered an HBV vaccination free of charge. The employee is not required to accept the offer of the vaccination.  In that instance, a waiver needs to be signed noting the refusal of the vaccination. 

Under the policy and procedures section of the written infection control plan, it clearly states that all category 1 and category 2 employees will be offered the vaccination. Anyone on your employee list who falls in category 1 or 2 will be required to have an HBV vaccination, or be provided the opportunity to have one.  Category 3 employees are not required to have or to be offered the vaccination.  Written documentation of either the dates the vaccination was administered (it is a series of shots) or the form stating the employee declined, has to be on file.

Infection Control Training

Section 3 involves creating an infection control plan for annual training and records. OSHA specifically states that training must be provided at four different times:

1. At the time of the initial assignment (i.e., when you are hired).
2. At least annually thereafter; the standard does not specify the length of the training, but OSHA does list certain concepts that need to be included in the training program (e.g., covering modes of disease transmission, information on the HBV vaccination, use of protective equipment, etc.). 
3. During the course of the year, if your audiology clinic has an updated or new procedure that is to be implemented, appropriate training must be conducted in a timely fashion to ensure that the new or updated procedures are understood, and that appropriate infection control procedures are integrated.
4. Any time an employee's status has changed (e.g., if someone has moved from a category 3 employee to a category 2 employee, despite the fact that they have been employed at that clinic for five years, OSHA requires that they undergo infection control training again). 

The written infection control template that I referred to earlier has an example of a training document.  The training document outlines what the training is going to cover and exactly when training is going to take place.  In addition, you want to provide a form to all training session participants to document their name, the date, and the information that was reviewed in the training.  The infection control template has this information that you can copy or modify for your needs, so you do not need to reinvent the wheel.  

Plan for Accidents and Accidental Exposure Follow-up

This section of the written infection control plan addresses what the health care provider needs to do in the event of an accident or accidental exposure (e.g., if a patient falls, someone gets a nose bleed, or gets sick. etc.). When an accident occurs, everyone in the office needs to know exactly what they need to do so that there is no confusion and they can tend to the accident right away. In addition, all employees must now what to do in the event of an accidental exposure.  Now, while the risk of HIV transmission in the audiology environment is unlikely and considered a rare event, exposures that may place someone at risk include percutaneous injury like a needle stick or a cut with a sharp object. 

Occupational exposure also includes coming into contact with mucous membranes or non‑intact skin (e.g., exposed skin that is chapped, abraded, or has blood, tissue or other potentially infectious bodily substances on it). In the event of an occupational exposure, the infection control plan needs to outline that testing for HIV will be required. 

HIV Tests. There are three basic types of HIV tests:  Antibody test, Antigen/Antibody test, and Nucleic Acid (RNA) tests. As the names suggest, an Antibody test detects for the presence of the antibodies for HIV and not specifically the virus. The Antigen/Antibody test and the Nucleic Acid test, are specifically designed to detect the presence of HIV. An HIV test may be one of two antibody tests: the Enzyme Immunoassay (EIA) or the “rapid test.” Blood will be drawn or oral fluid may be collected to screen for HIV antibodies.  The main difference between these two tests is that the EIA takes about two weeks to get results whereas the rapid test takes about 10 to 20 minutes. 

So what does it mean when you get your results back? If you test negative, follow‑up testing will be required because it takes anywhere from two weeks to 6 months in order for your body to start producing antibodies for HIV.  Even if you get tested immediately after an occupational exposure and you test negative, that does not mean you are clear. There should be a retest in 3 months. Even if you test negative in 3 months, you should have another retest in 6 months, because it takes that long for seroconversion to occur.  If you test positive, a confirmatory test such as the Western Blot must be performed.  In the event that the test is truly positive, it is going to require medical treatment with the necessary medical professionals; that is beyond the scope of the infection control plan. I think it is important for everyone to understand that in the event of an occupational exposure, there are certain things that have to happen which are outlined in section 4 of your infection control plan (Emergency Procedures).

Post Exposure Plans and Records

This section is an extension of the section that covers accidental exposure and follow‑up.  This section includes all the specific steps that need to be taken after an occupational exposure, and within what timeframe they need to be completed.  For example, this will include not only the description of the incident, but it will also outline when and where testing should be done.  It is not necessarily going to have the results of the testing on file.  It is the written document of post‑exposure records that clearly demonstrates that an employee who had an occupational exposure is following the necessary steps to get the appropriate testing done. 

Implementation Protocols

For the sections we just discussed, you can take the written infection control plan template and copy most of the verbiage word-for-word. It is standard information that is not necessarily unique to any particular clinic (with the exception of a few minor details). The Implementation Protocols section is clinic-specific. This section outlines how audiology procedures will be executed in a manner that is consistent with eliminating the mode and the route of microbial transmission. This section involves creating clinic-specific work practice controls that integrate the necessary standard precautions, including the use of appropriate products to get the job done. 

Implementation protocols involve taking an inventory of the audiology services your clinic provides, and creating a necessary work practice control for each service. A work practice control is a profession‑specific written protocol outlining how your clinic will perform procedures in a manner that is designed to minimize the potential spread of disease.  First, make a list of the services that are provided in the clinic. Next, start creating the necessary written procedures, making sure to implement the required standard precautions.  For example, say that your practice dispenses hearing aids.  Under the umbrella of hearing aid dispensing, there might be a variety of services that you provide.  Of those services, you need to identify which ones you perform, and create a work practice control for each service you provide/perform. 

To illustrate, if your clinic takes ear mold impressions, conducts hearing aid fittings, modifications and listening checks, and those are the only services you perform with regard to hearing aid dispensing, then you will be responsible for creating four specific work practice controls in the Implementation Protocols section of your written infection control plan.  If you also provide verification and real ear testing, as well as drop-off hearing aid services, you will have to make sure that you have six work practice controls that address all these services.  Furthermore, if you also provide diagnostic testing, you need to make a list of what it is that you do in terms of diagnostics.  Then, you need to identify how many work practice controls you need to develop, and integrate them into your written infection control plan.  You would repeat this for vestibular testing, and any other service that you provide. 

Once you have the list of work practice controls, the written procedures that you create must integrate the following five standard precautions:

• Appropriate personal barriers must be worn when performing procedures that may expose you to infectious agents.
• Hand hygiene must be performed before and after every patient contact and after glove removal.
• Touch and splash surfaces must be pre-cleaned and disinfected.
• Critical instruments must be sterilized.
• Infectious waste must be disposed of appropriately.

Personal barriers. Personal barriers involve the use of things such as gloves, protective eyewear, disposable masks, lap wear or aprons.  You must wear gloves any time that there is an open or visible wound on the patient in the area, or residing near the area, that you are going to be manipulating. If there is an open or visible wound on your hands you will also need to wear gloves, because you need to protect the patient as well. The other time gloves have to be worn is when you are handling contaminated objects that have not been cleaned or disinfected.  You do not want to handle anything that resides in the ear or has been removed from the ear with your bare hands, unless you have cleaned or disinfected the object.  It doesn't matter what kind of gloves you use.  There are many different types (e.g., latex, nitrile, vinyl).  Many people are shying away from latex gloves because of latex allergies.  Nitrile gloves will not react with impression material so those have become more popular in the audiology clinic.  You can get nitrile gloves with or without powder; that is a matter of preference.  It is important to make sure that you invest in gloves that fit appropriately, like a second skin.

Hand hygiene. The second standard precaution is hand hygiene. Hand hygiene is the single most important thing anyone can do to minimize the potential spread of disease. Hand hygiene should be performed with liquid, medical-grade soap and water. No‑rinse hand degermers should be used only in instances where you do not have easy access to a sink with running water. The AMA and CDC have approved of use of no rinse hand degermers. 

When do you have to perform hand hygiene? First and foremost, you are required to perform hand hygiene immediately before the patient appointment as well as immediately following the patient appointment.  If you change rooms between patients, you can wash your hands when you go into the second room before the second patient.  This will meet the definition of “after the patient appointment” for your first patient as well as “before the patient appointment” for the second patient.  You do not have to wash your hands after you see Mrs. Smith and then walk into the next room and wash your hands again because you're now going to see Mr. Jones.  In addition, hands must be washed between what are considered dirty and clean activities.  For example, it is an OSHA requirement that upon removal of gloves, you need to commence with hand hygiene procedures.  The reason for this is that if you are wearing gloves, you are performing what is considered a dirty activity.  Upon removal of the gloves, it is possible that you may come in contact with a contaminant on the outside of the gloves. You also need to wash your hands any time during the patient appointment that you feel you need to.

Cleaning and disinfecting. When it comes to cleaning and disinfecting as outlined by OSHA, any touch or splash surface needs to be cleaned and then disinfected between patients.  These are horizontal surfaces that come in direct or indirect contact with the patient's hands or areas where either the clinician or the patient can sneeze upon. These surfaces include the table where you provide counseling services, the armrest of the chair that resides in your booth, and the response button.  It also includes over the ear TDH‑39 air conduction headphone cushions as well as your bone conduction vibrator.  Those are all considered touch or splash surfaces. 

To provide specific definitions, “cleaning” simply means removing gross contamination, such as doing a quick wipe-down of the area that you intend to disinfect.  Germs are not necessarily killed but it is an important precursor to disinfecting as well as sterilizing whether you see something there or not.  In contrast, the term “disinfect” is a process whereby germs are killed and the spectrum of kill really depends on the kind of product you are using.  Clean and then disinfect any touch and splash surface after you have seen one patient and prior to seeing the next patient.

You have a choice of what are considered hospital-grade disinfectants, or other disinfectants and cleaners that don't fall under the category of hospital grade. A hospital-grade disinfectant is a disinfectant that has registered with the FDA and has a kill sheet that demonstrated in a lab that the product specifically killed certain micro‑organisms. Some other disinfectants that are not considered hospital-grade have many of the same active ingredients as the hospital grade disinfectants; however, if they did not undergo the FDA registration procedure, they cannot refer to themselves as hospital-grade disinfectants. The active ingredients will tell you what kind of micro‑organisms a product is going to kill.  If you work in an environment where it is necessary for you to have a list that shows that a specific product exactly kills a specific list of micro-organisms, my suggestion is you go to the hospital-grade disinfectant where the product manufacturer can provide you with a kill sheet. 

Another thing to keep in mind that is often overlooked when it comes to disinfectants, is “dwell time.”  Dwell time refers to how long the liquid substance of the disinfectant needs to be wet on the surface prior to wiping it down or letting it dry.  Many of the disinfectants in the audiology community have a three-minute dwell time.  There is a new‑peroxide product that has a 30 second dwell time and one-minute dwell time.  These are for the centers that see a large number of patients a day where every minute and every second counts.

Critical instruments. With regard to cleaning and disinfecting, the area where I get the most questions about and where I see a lot of confusion is in regard to critical instruments.  According to OSHA, all critical instruments need to be cleaned and sterilized.  Critical instruments are defined as:

• Any instrument that is introduced directly into the bloodstream (which is nothing we would be reusing). 
• Any non‑invasive instrument that comes in contact with mucus membranes or bodily substances (anything you stick in the ear that makes contact with cerumen).
• Any instrument that can potentially penetrate the skin from use or misuse.

This definition is clear.  If you are ever in doubt, you need to ask yourself, what is this instrument and does it meet any of the three bullet points that you see here?  If it meets at least one of the bullet points, then you need to clean and sterilize that item prior to reuse. 

Whereas the term “disinfect” is a process whereby germs are killed, “sterilize” is a process whereby all germs are killed each and every time, including what are referred to as their endospores (which disinfection does not achieve). The process of sterilization has specific product requirements because most of the items that we will sterilize in the audiology environment are comprised of rubber, acrylic, silicon and plastic.  In the case of these materials, we are not able to sterilize using any procedure other than a cold sterilant. Cold sterilization involves using a chemical that includes the active ingredients of 2% or higher concentrations of glutaraldehyde, or 7.5% or higher concentrations of hydrogen peroxide.  If you use any glutaraldehyde-based product, the soak time in order to achieve sterilization is 10 hours, whereas for the hydrogen peroxide-based product, soak time is six hours. There is also a something referred to as a “use/reuse” time.  When you pour the chemical from the jug into the tray, you can continue to reuse that same solution up to a specified period of time.  This is why cleaning the instrument prior to submerging it is important; you do not want to compromise the sterilization and you want to ensure that you can reuse that solution for the maximum amount of time.  For glutaraldehyde solutions, the use/reuse time is 28 days; for hydrogen peroxide solutions it is 21 days.  Be sure to read instructions prior to use. 

There are two main cold sterilants available: Wavicide and Sporox. They are both available in gallon sizes.  The Wavicide is also available in the quart size. Again, be sure to read the instructions to make certain that you are using these products appropriately.  If you are going to use these products in your clinic, you need to request a Material Safety Data Sheet, or MSDS.  This is a document that outlines the hazards associated with the chemical products. OSHA requires these to be on file, as does JCAHO.  Just because you buy the product does not mean that you are automatically going to receive the MSDS (it is not necessarily included in the packaging).  If you need it, contact the vendor that you purchased your products from and ask them for an MSDS sheet. 

Depending on how often your office performs certain activities, it might be cost-effective for you to take the approach of using disposable audiology supplies rather than reusable items that require cleaning and sterilizing.  There are a variety of products available that are one‑time use only, and you throw them out afterwards.  There is no need to clean, disinfect or sterilize.  The disposable route eliminates a lot of potential infection control errors due to human error or potential laziness. 

​Infectious wastes. Our last standard precaution is infectious wastes.  Sharp instruments such as any of the scalpels or blades that you may use in your environment need to be disposed of in a sharps container.  A sharps container is a puncture‑proof container.  Any other contaminated waste, even if it has cerumen or a little bit of blood on it, can be thrown out in the regular trash. 

Audience Poll

Poll Question: It is acceptable to handle a hearing instrument a patient takes out of his or her pocket with your bare hands – True or False?

Dr. Bankaitis: The answer is false. If the patient comes into your office and they either take the hearing instrument out of their pocket or their purse, you should not handle that hearing instrument with your bare hands unless you are going to clean and disinfect it first. The study that was done in 2002 (and it has been repeated since then) clearly shows that there is a multitude of bacteria growing on patients’ hearing instruments, some of which are not considered part of the normal ear canal flora. From whichever source the patient removes the hearing instrument (their ear, their pocket, their case, etc.), you need to use a gloved hand, take the instrument with a disinfectant towelette, or clean and disinfect the hearing aid surface area prior to handling. 

Poll Question: It is always required to handle hearing instruments with gloved hands, no exceptions – True or False

Dr. Bankaitis: The answer is false.  You can have the patient put their hearing instrument in a disinfectant towelette that will serve as a barrier, so you are not making contact with your bare hands.  You can use the towelette to clean and then disinfect the surface, or wear gloves while doing so, and then handle it with your bare hands. If you are not going to clean and disinfect the hearing aid, you need to wear gloves when handling it.

Poll Question: Gloves should always be worn by when removing ear mold impressions from a patient's ears – True or False

Dr. Bankaitis: The answer is true.  You do not have to wear gloves while making the ear mold impression because you're first going to wash your hands.  Some of the material that gloves are made of can interfere with the curing of impression material. Once you pull the ear mold impression out of a patient’s ear, even if it is a relatively clear auditory canal, you must use gloves.  Keep in mind that anything that was on the surface of the external auditory canal, such as residual cerumen, moisture, blood, or other bodily substance - whether you can see it or not - is now going to be on the surface of that ear impression.  You need to treat the ear impression as if you just removed it from a body orifice, which is what you have done.  I recommend you wear gloves while you're handling ear mold impressions that are removed from the ears. 

Poll Question: After use, air conduction headphones must be: disinfected, sterilized, or sanitized?

Dr. Bankaitis: Headphones make contact directly with the patient's skin, so they need to be disinfected.  Do not use the word “sanitize”.  Sanitize is a very broad, general term, and what I refer to as a “garbage can” term because its definition is ambiguous.  When you use the word "sanitize" it is not clear as to whether you are disinfecting or sterilizing.  I would recommend only using the terms disinfect and sterilize because those terms have specific definitions. 

Poll Question: After use, stainless steel cerumen management instrumentation must be: disinfected, sterilized, or sanitized?

Dr. Bankaitis: Stainless steel cerumen management instruments are considered critical instruments so they must be sterilized prior to reuse. 

Creating a Work Practice Control - Otoscopy

For these examples, I will show you how to go about creating a work practice control for an otoscopic examination.  There is more than one work practice control that you can create for otoscopy.  The work practice control you create for otoscopy will depend on your infection control philosophy as well as what kind of materials you are using in your practice.

Example One - Disposable Speculum

In this example, the patient has absolutely no ear drainage. We are using disposable speculum; we have already completed hand hygiene procedures.  So as I think this through, I know that I need some sort of personal barrier, whether it is a glove or a towelette.  Once I'm done performing the otoscopic examination, I need to physically remove the speculum from the otoscope head. I want to make sure that I am not touching that contaminated speculum with my bare hands.  We have already established that we performed hand hygiene. There is nothing that we need to clean or sterilize because we are using disposable specula.  The only other thing we need to consider is to ensure that we dispose  of the speculum in the trash. 

This is what an acceptable work practice control will look like for otoscopy using a disposable speculum:

• Attach a new disposable speculum to the otoscope. 
• Perform otoscopy. 
• Remove speculum using gauze and tissue. 
• Dispose of the speculum in the trash. 
• Return the otoscope to retesting location. 

Example Two - Reusable Speculum

In this instance, I am using a reusable speculum. I will need to write a different work practice control that takes into consideration the fact that we are using a reusable speculum. Once we perform otoscopy, we will place the speculum in a specific tray where we can take it to the sterilization room because a reusable speculum requires sterilization. 

Therefore, the work practice control for a reusable speculum would be:

• Attach a new disposable speculum to the otoscope. 
• Perform otoscopy. 
• Remove speculum using gauze and tissue. 
• Place speculum in tray for later sterilization prior to reuse. 
• Return the otoscope to retesting location. 

The point of sharing these two examples is to show you that there is more than one way to write a work practice control.  In my clinical experience, I have had two different work practice controls for otoscopy that clearly outlined how we would perform the procedure.  In this case, you want your employees to know exactly what to do in the event a patient has or does not have a draining ear, or has any kind of visible wounds in the vicinity of the ear as well.

Conclusion

The take-home message today is that infection control is a required element of audiology practice.  You need to create a written infection control plan with work practice controls that are unique to your clinic.  Use standard precautions as your guide and integrate appropriate products to ensure that you are meeting the goals of the infection control plan.  Implement the plan, and rely on resources to guide you. 

For further information, refer to my blog, www.aubankaitis.com, where you can find a section on infection control.  The book, Infection Control in the Audiology Clinic, is available via Oaktree Products. Please feel free to email me at au@oaktreeproducts.com for a copy of the written infection control plan template that I discussed.  It includes all of the required sections, except the Implementation Protocols section that will be unique to your clinic.  Please feel free to contact me as well if you need clarification on any of the information in this course, or if you have further questions.  Thank you for your time and attention.

Questions and Answers

Question: How do you safely dispose of these products?

Dr. Bankaitis: I assume if you're talking about anything that is contaminated in the clinic that is disposable.  You can safely dispose of contaminated items in the regular trash; some people use a bio‑hazard bag, although that is not necessary.  If you're referring to sterilants, you need to check with your local authorities in terms of appropriate disposal of those types of chemicals.  Although I will tell you that in most places, with the exception of Washington and Oregon, you can dispose of glutaraldehyde or Sporox down the sink with running water. Again, check with your local authorities.  In terms of how environmentally safe is this?  A lot of people have been switching from glutaraldehyde to Sporox because hydrogen peroxide, although it is still a chemical given its concentration, is more environmentally friendly in terms of disposal.  In addition, it doesn't have the strong and unpleasant fume that glutaraldehyde has.  So if you are going to be using a glutaraldehyde-based product you need to make sure that it's placed in a highly ventilated area. When in doubt, go with Sporox. 

Question: When placing contaminated items in a covered container awaiting sterilization, what should the label say? 

Dr. Bankaitis:  Let's say you have your admittance tips.  There should be a location in the audiometric booth where you put the contaminated tips once you use them and preferably it should have a lid on it.  There should be something that clearly indicates “clean” versus “used” so there is no mistake as to which ones are contaminated or not.  Then at the end of the day, you walk that container down to the designated area where you're going to be able to clean and then sterilize those items.