Needlesticks remain an employee health challenge

Success story is not yet complete

"Nothing will give me back my life as it was before HIV and HCV were a part of it. But I would like my experience to be used to prevent similar tragedies from happening to health care workers …"Lisa Black, RN, BSN, shared her needlestick experience with Advances in Exposure Prevention in 1999.

Needle safety is a major success story of employee health, although it's one for which the final chapter has yet to be written.

Health care workers once viewed needlesticks as just part of the job. Management considered needlesticks the fault of inattentive or careless employees. Meanwhile, in the 1980s, 12,000 health care workers a year were contracting hepatitis B from bloodborne pathogen exposures.

The U.S. Occupational Safety and Health Administration (OSHA) began requiring safer devices in 1991, but the Needlestick Safety and Prevention Act spurred a full-scale implementation. As a result, needlesticks declined by 51% from 1993 to 2001, according to EPINet data collected from a sampling of hospitals by the International Health Care Worker Safety Center at the University of Virginia in Charlottesville.

Melody Sands, MS, director of OSHA's Office of Health Enforcement, recalls sitting in a congressional hearing room, gazing at a poster-sized sign that contained a phrase from the OSHA bloodborne pathogen standard: Whenever engineering controls can be used to eliminate or reduce exposure, they must be used.

"I believe those words have resounded over the last decade," says Sands.

The bloodborne pathogen standard remains the most frequently cited OSHA standard in hospital inspections. Of the 138 citations issued last year, hospitals were most likely to receive a citation for having an inadequate exposure control plan or failing to use safety-engineered sharps devices.

More safety measures are needed

Needlesticks persist, both from safety-engineered devices and from devices that have not been converted for safety, at a rate of about 24 injuries a year per 100 beds, according to the most recent EPINet data. Making further progress is a challenge for hospitals.

"In the next 25 years, it's really important that exposure to all infectious diseases is not something we should become apathetic about," says Amber Hogan, MPH, who worked on compliance directives and the bloodborne pathogens standard while at OSHA. She now is manager of health care policy and advocacy at Becton, Dickinson and Co. of Franklin Lakes, NJ.

In fact, pioneers in the field of needle safety, such as Janine Jagger, PhD, MPH, director of the safety center at the University of Virginia, and June Fisher, MD, director of the TDICT (Training for the Development of Innovative Control Technologies) Project at the University of California at San Francisco, continue to work for improvements.

Peter Lurie, MD, MPH, was head of the staff union at San Francisco General Hospital when the AIDS epidemic began. Some nurses became so fearful that they quit rather than care for AIDS patients. "Ironically, the consciousness about HIV needlesticks was greater than the consciousness about other needlestick problems that had been around for a long period of time and killed more people," he says.

Lurie recalls reading that the risk of a health care worker contracting AIDS was equal to the lifetime risk of a firefighter or police officer dying on the job.

"Those are viewed as dangerous occupations. I was doing one that was just as dangerous. That put it in perspective for me," says Lurie, who is now deputy director of Public Citizen's Health Research Group in Washington, DC.

In 2001, Public Citizen and the Service Employees International Union (SEIU) petitioned the FDA to ban some conventional devices for which safety-engineered alternatives were available. The agency denied the request in 2005.

"I still think there are lots of missed opportunities [to reduce sharps injuries]," says Lurie.

Here are some issues that needle safety experts say should be addressed by employee health professionals:

  • Converting to safety devices in the operating room.

The first emphasis of needle safety involved hollow-bore needles, which are associated with the highest risk of transmission of bloodborne pathogens. However, the operating room is now the site of the greatest number of exposures, and surgeons have been reluctant to switch to blunt suture needles.

In 2005, the American College of Surgeons endorsed the use of blunt suture needles. A 1998 study by Jagger found that cuts or needlestick injuries occur in 1% to 15% of operations — and only 6% of those occurred during hand-to-hand passing of instruments.1

Surgeons need to participate in demonstrations of the newer blunt suture needles to be convinced that they do not adversely affect the surgical procedure and patient care, Fisher says. Employee health nurses should work with national professional organizations, such as the Denver-based Association of Operating Room Nurses (AORN), to promote safer OR practices, she says.

"You have to have champions who are willing to adopt appropriate new devices," Fisher says.

  • Continuing to seek better devices.

Huge advances have been made in needle safety technology, with devices that are easier to use and less likely to fail. OSHA requires employers to consider new technology every year as part of updating the exposure control plan — but hospitals may not be adequately fulfilling that task.

"People have chosen their safety technologies years ago and are not becoming aware of the new technologies available to them," says Hogan.

Vendors can provide information on new devices. A starting point is the list of safety devices from the National Alliance for the Primary Prevention of Safety Sharp Injuries at www.nappsi.org/safety.shtml; the California Department of Health Services at www.sharpslist.org; or the International Sharps Injury Prevention Society at www.isips.org/safety_products.html.

  • Getting buy-in from frontline workers.

If employees are disabling the safety features or failing to activate them, that may be a sign that they aren't satisfied with the device or weren't involved in the selection, says Craig Molton, senior industrial hygienist with OSHA. OSHA continues to get questions regarding the requirement for involvement of frontline health care workers in the selection of devices.

"The frontline people have to have a capability to say what will work for them," says Sands.

Hospitals may use one of many methods to solicit input, according to a Jan. 12, 2006, OSHA letter of interpretation, including: joint labor management safety committees; involvement in informal problem-solving groups; participation in safety meetings and audits, employee surveys, worksite inspections, or exposure incident investigations; using a suggestion box or other methods for obtaining written employee comments; and participation in the evaluation of devices through pilot testing.

"A simple open request for input is adequate," according to the OSHA interpretation, but that request must be "effectively communicated to employees."

While minimal input may satisfy OSHA, it is worthwhile to take the time and effort to involve frontline workers in the hands-on evaluation and selection of devices, says Fisher. The selection of the right devices will determine the success of your sharps safety program, she adds.

To help with that process, evaluation forms for the selection of safe sharps are available at www.tdict.org.

  • Improving work practices.

Creating a culture of safety requires altering habits. It is a lot tougher than just buying new safety devices. Research shows that other aspects of the work environment may impact needlesticks. For example, a yet-unpublished study of 2,000 nurses in 13 health care facilities found a link between nurse-physician collaboration and nursing management and blood and body fluid exposures.

An earlier study found that nurses working in a unit with low staffing and a poor organizational climate were twice as likely to suffer a needlestick as those in well-staffed, well-organized units.2

Reducing needlesticks involves more than just following the steps of selecting and purchasing better devices, says Fisher.

"You have to look at stress, fatigue, staffing, hours worked, and you need to look at the work environment," she says. "They're all interrelated. You should begin to use a comprehensive approach to a safe work environment."

References

1. Jagger J, Bentley M, Tereskerz PM. Patterns and prevention of blood exposures in operating room personnel: A multi-center study. AORN J 1998; 67:979-996.

2. Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health 2002; 92:1,115-1,119.