Cardboard Shipping Boxes

Q: We have a battle going on at our hospital regarding whether cardboard boxes can remain in a Pharmacy clean storage room. Some staff is saying the boxes must go. I thought that was only the case in an OR clean sterile room. IN this situation, the Pharmacy clean storage room is 1-hour fire rated. I guess this question will apply to all of our clean storage rooms in our hospital

A: You have two different standards at play, here. From a Life Safety Code point of view, you are compliant. Cardboard boxes are combustible, and having multiple cardboard boxes stored in a room requires the room to be maintained as a hazardous area. According to section 19.3.2.1 of the 2012 Life Safety Code, the room would have to be 1-hour fire-rated or be sprinklered. You say the room is 1-hour fire-rated, so you are compliant with the Life Safety Code. There is no other Life Safety Code requirement that would prevent the storage of cardboard boxes in that room.

However, as I said, there is another standard at hand here. From an Infection Control point of view, cardboard boxes used for shipment presents many problems:

  • The boxes are dirty. They have been riding in the back of trucks for days, and they have been sitting on receiving docks which is a very transient environment. These boxes are not acceptable from an Infection Control consideration to be stored in a clean environment, let alone a sterile environment.
  • The boxes may contain insects or vermin. In some cases, you have no idea where these boxes came from. Insects can make a home in the cardboard boxes and then be shipped to your facility. Vermin have been known to hide in a cardboard box and also be transferred to other places.
  • If left on the floor, the boxes may become wet. A wet cardboard box becomes soggy and falls-apart and leaves a trail of contaminants that provides a place for mold or mildew to grow.

While there may not be a specific standard in the accreditation organization’s manual, or a CMS CoP standard that prohibits cardboard shipping boxes from being stored in a clean environment (i.e. pharmacy storage room), it is generally understood that most surveyors and inspectors will cite an organization for doing so. This is due to the perceived Infection Control issues described above. They would typically cite the facility under a general duty standard that requires the organization to maintain a safe environment for their patients and staff.

My advice is to remove the cardboard shipping containers from the facility at the point where you receive them (i.e. receiving dock) and discontinue storing any paper or cardboard container on a floor that has the potential to be wet. Discuss this issue with your Infection Control specialist. I’m sure they have an opinion on cardboard shipping boxes.

Cardboard Boxes Stored on the Floor

Q: Is there a specific code reference in regards to storage of boxes on the floor? I am trying to locate any specific code language for preventing the use of the floor for direct storage of boxed items.

A: I am not aware of any NFPA code or standard that is referenced by the Life Safety Code that would prevent cardboard boxes from being stored on the floor. However, the hospital (or healthcare organization) should have Infection Control guidelines on this issue. Whenever I see this situation in the field it is always referred to the IC practitioner for their decision.

There are two main issues at work whenever cardboard is setting on the floor:

  1. Moisture on the floor could cause rot, mold, and other growth in the cardboard.
  2. Shipping cardboard boxes could contain insect and even vermin which could spread to other areas of the facility.

Please check with your accreditation organization and your state and local health departments to see if they have any regulations preventing cardboard boxes from being stored on the floor.

Corrugated Cardboard Boxes

Q: I am pushing to get all corrugated cardboard out of all areas of the hospital – not allowing materials management to send any items out of their department in corrugated cardboard. Is there a specific standard that support this?

A: There is no specific NFPA standard that speaks directly to corrugated cardboard boxes/shipping boxes. This is part of infection control because corrugated cardboard boxes are susceptible to moisture, water, vermin and bacteria during warehouse or storeroom storage, as well as transportation environments. The hospital must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases and all areas of the hospital must be clean and sanitary. This includes all hospital units, campuses and off-site locations.

Cardboard boxes are manufactured and imported from many areas around the world without means of decontamination, especially for a sterile environment. Also, prior to delivery to a hospital cardboard boxes have been stored in different types of warehouses, with no protection for a sterile environment.  Since cardboard boxes cannot be washed, they cannot be part of your regular required cleaning schedule.

Cardboard boxes are usually delivered to hospital receiving docks from other shipping dock locations on carts or pallets, prior to arriving into a health care facility.  Mice, insects, vermin, dirt with pathogenic organisms can be carried into a hospital within the cardboard boxes used as external shipping cartons.  Also, corrugated cardboard boxes can and do shed particles that contribute to dust in hospital environments, whereby microorganisms can hitch a ride. If corrugated cardboard becomes wet, it becomes a source for bacterial growth.

Please be aware that cardboard boxes and or cardboard shelving units should not be allowed or found in areas such as:

  • OR storerooms
  • Central Supply
  • Clinical areas

Also, do not use cardboard boxes to store items in a dirty utility room. Cardboard boxes should never be used to store patient supplies- as these are considered dirty. You may wish to discuss this issue with the hospital Infection Control person as part of the hospitals routine scheduled environmental surveillance tours.

Cardboard Shipping Boxes

I have been receiving quite a few questions regarding cardboard shipping boxes and whether or not they can be used for general storage in storage rooms throughout the hospital. We’re not talking sterile environments, like an OR storage room, but just general utility rooms in various locations in the facility.

To look at the over-all picture, there are two different standards at play, here. From a Life Safety Code point of view, the boxes could be compliant. Cardboard boxes are combustible, and having multiple cardboard boxes stored in a room requires the room to be maintained as a hazardous area. According to section 19.3.2.1 of the 2012 Life Safety Code, the room would have to be 1-hour fire-rated or be sprinklered. If the room is 1-hour fire-rated with 3/4-hour rated door assemblies that are self-closing and positive latching, then you would be compliant with the Life Safety Code. There are no other Life Safety Code requirement that would prevent the storage of cardboard boxes in that room.

However, as I said, there is another standard at hand here. From an Infection Control point of view, cardboard boxes used for shipment presents many problems:

  • The boxes are dirty. They have been riding in the back of trucks for days, and they have been sitting on receiving docks which is a very transient environment. These boxes are not acceptable from an Infection Control consideration to be stored in a clean environment, let alone a sterile environment.
  • The boxes may contain insects or vermin. In some cases, you have no idea where these boxes came from. Insects can make a home in the cardboard boxes and then be shipped to your facility. Vermin have been known to hide in a cardboard box and also be transferred to other places.
  • If left on the floor, the boxes may become wet. A wet cardboard box becomes soggy and falls-apart and leaves a trail of contaminants that provides a place for mold or mildew to grow.

While there may not be a specific standard in the accreditation organization’s manual, or a CMS CoP standard that prohibits cardboard shipping boxes from being stored in a clean environment (i.e. pharmacy storage room), it is generally understood that most surveyors and inspectors will cite an organization for doing so. This is due to the perceived Infection Control issues described above. They would typically cite the facility under a general duty standard that requires the organization to maintain a safe environment for their patients and staff.

My advice is to remove the cardboard shipping boxes from the facility at the point where you receive them (i.e. receiving dock) and discontinue storing any paper or cardboard container on a floor that has the potential to be wet. Discuss this issue with your Infection Control specialist. I’m sure they have an opinion on cardboard shipping boxes.