What is The Joint Commission's position on managing cardboard or corrugated boxes and shipping containers?

Any examples included in this response are for illustrative purposes only.

Fire Safety:
Cardboard in storage quantities (recommend consultation with your Fire Marshal) should be placed in hazardous areas protected per LS.02.01.30 and cannot obstruct the means of egress in accordance with standard LS.02.01.20. Containers that are contaminated should be removed based upon the cleanliness requirements of the storage area. Many suppliers have paper or cardboard distribution boxes that are designed for use in laboratory, pharmacy, patient care areas or sterile storage areas.  
 
Infection Prevention and Control: 
The Joint Commission recommends that when creating or revising IC–related policies, health care organizations apply a hierarchical method as described in The Joint Commission Perspectives, April 2019, to address the various IC requirements on managing cardboard or corrugated boxes and shipping containers.   As discussed in the Perspectives, health care organizations must first comply with the Rules and Regulations as described in Standard LD. 04.01.01, Conditions of Participation or Conditions for Coverage for those organizations that use Joint Commission Accreditation for deemed status purposes, and Manufacturers’ Instructions for Use.  Other components of the hierarchical method include evidence-based guidelines and national standards such as those promulgated by the US Centers for Disease Control and Prevention, and consensus documents, for example, those developed by national trade organizations.

Shipping containers, especially those made of a corrugated material, serve as generators of and reservoirs for dust.  Corrugated cardboard boxes are susceptible to moisture, water, vermin and bacteria during warehouse or storeroom storage, as well as transportation environments.  Boxes and containers may have been exposed to unknown and potentially high microbial contamination.  

When organizations are making a determination as to whether these boxes and containers are appropriate to be located in a certain area, they should consider the potential adverse impact of dust, moisture, bacteria or other contaminants on that area.  An organization may determine, for example, that it is not appropriate for such boxes and containers to be located in a pharmacy (e.g. USP 797) or in sterile storage (e.g. AAMI ST79).

Other considerations might include, for example, where to load or unload supplies, criteria for content break-down areas, and what level of packaging to keep within the area in question. The process could also address the use of boxes that came out of the shipping container where box labeling is essential to proper use (for example, expiration dates, contents, ingredients, directions for use, etc.).  

Once a process for managing cardboard or corrugated boxes and shipping containers is developed, health care organizations should ensure compliance, noncompliance would be reflected in a score at IC.02.02.01 EP 4.
 
AAMI ST 79 5.2.1 General Considerations: 
Clean or sterile items to be transported to central processing and storage areas within the facility should be removed from their external shipping containers before they enter the storage areas of the department. Any instructions for use accompanying the items should be kept with the items.  

Additional Resources:
The Joint Commission, (April 2019) Clarifying Infection Control Policy Requirements, Perspectives, Volume 39, (Issue 4), pages 15 – 17.