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By Gary Evans, Medical Writer
Although there are individual success stories, overall needlesticks and mucocutaneous exposures to healthcare workers are on the rise, according to two leading surveillance groups.
The Association of Occupational Health Professionals in Healthcare (AOHP) recently released a report1 on its EXPO-S.T.O.P. (EXPOsure Survey of Trends in Occupational Practice) for 2016 and 2017. Overall, there has been a 19% increase in sharps injuries over the last three AOHP surveys.
“We believe the stress, rushing, and fatigue that accompany higher workloads may be a contributing factor in the significant rise in sharps injuries,” the authors concluded. “Under such stress, fail-proof and simple safety-engineered devices are crucial, as is competency-based training.”
Study co-author Terry Grimmond, FASM, BAgrSc, GrDpAdEd, a microbiology consultant in Hamilton, New Zealand, said gains seen after passage of the 2001 Needlestick Safety and Prevention Act are not being sustained. In general, hospitals have adopted safety-engineered devices (SEDs), but some are not following the OSHA requirement to annually review new, safer devices like those with automatic needle retraction systems, he says.
“Inevitably, it comes down to resources — both staff and financial,” he says. “The successful strategies are there. We need additional resources to purchase safer safety-engineered devices and to spend more on staff education and training. We need to move the culture to one that has a zero-injury objective.”
Instead, there is an acceptance of some level of injuries and exposures at too many hospitals, he adds.
“It is unacceptable that healthcare workers think sharps injuries are part of the job,” Grimmond says. “If no other industry tolerates such a safety culture, why does healthcare? If industry offices have large signs stating how many days since last ‘lost day,’ why don’t hospital foyers?”
Increases in sharps injuries and exposures also are reported by hospitals to the International Safety Center’s Exposure Prevention Information Network (EPINet).
“The increases aren’t subtle, either,” Amber Mitchell, DrPH, MPH, CPH, director of the safety center, tells Hospital Employee Health.
For example, the 21.4 sharps injuries per average daily census (ADC) in 2013 rose to 33.8 in 2017, she says.
“We have seen the same disheartening increases for mucocutaneous exposure incidents,” she says. “In 2013, there were 5.9 incidents per ADC, and in 2017, 10.1. These are often the most underreported, yet potentially hazardous given more than 50% are to unprotected eyes.”
The selection of engineering controls and personal protective equipment (PPE) should be based on evaluations completed by frontline healthcare workers, she emphasizes.
“It isn’t enough to simply purchase devices with sharps injury prevention features — they must be activated and disposed of safely,” Mitchell says. “They also need to be immediately accessible so that there is no deterrence to use every single time they are needed.”
Despite the overall trends, the AOHP reports success stories from employee health professionals who are showing these exposures can be significantly reduced. Indeed, replacing active safety devices with passive designs that automatically shield the needle led to a dramatic reduction in exposures at one hospital system. (For more information, see related story in this issue.)
“[These successful facilities] take this very seriously. I think organizations that don’t do that are going to stay the same, or creep up in incidence,” says AOHP report co-author Linda Good, RN, PhD, COHN-S, manager of occupational health services at Scripps Health in San Diego.
A common theme in less successful organizations is a lack of management commitment to prioritize needlestick prevention. “The leadership prioritization is number one in my mind, and everything kind of flows from that,” Good says.
In education and training, one should not assume that the staff know how to use safety-engineered devices, she adds. As healthcare workers float to different areas of a hospital, they may end up using an injection device they are not familiar with, Good says.
“In a lot of the injuries that we are seeing, they have a safety-engineered device, but they are not activating it properly or in the proper sequence,” she says. “It results in an injury before the needle is sheathed or retracted.”
Next-generation products have come out in recent years that do not require the worker to activate a safety mechanism, but it takes careful planning to switch out safety-engineered devices.
“One of the challenges is that with group-buying contracts, they may not feel that they have the option of exploring other SEDs because it is not within the current group purchasing options,” Good says. “It is part of the OSHA mandate that hospitals take a look at various options and use them if they are proven to be safer.”
Development and adoption of sharps safety devices was driven in large part by the emergence of the HIV/AIDS epidemic in the 1980s and 1990s. It is difficult to overemphasize the fear of needlesticks when HIV was considered a terminal diagnosis. Now, it is a largely manageable, chronic disease. A recently announced national plan by the CDC and other federal agencies has ambitious targets of a 75% reduction in infections in the next five years and a 90% reduction in 10 years.2
The plan calls for an aggressive testing and treatment approach that links rapid HIV infection diagnosis with initiation of drugs that can reduce circulating virus to undetectable levels. There are approximately 1 million people living with HIV infection in the U.S., with some 40,000 new infections each year. Testing is a critical first step, as the CDC estimates that nearly 40% of people with HIV either do not know about their infection, or know but are not in treatment to suppress the virus. This group accounted for 80% of HIV transmission in 2016, the CDC reported. A higher titer of circulating virus presents greater risk to healthcare workers if there is a blood exposure to these patients such as needlesticks.
“The issue is that half of the people out there with HIV don’t know it — and we don’t know it,” says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology. “We can’t be complacent.”
Although a major concern early in the epidemic, hospital transmission of HIV now is exceedingly rare with standard precautions, sharps safety devices, and effective post-exposure prophylaxis treatments for exposed workers. In addition, more than half of people with HIV in the U.S. are under treatment, which means they pose virtually no risk of occupational transmission.
“Healthcare workers who are exposed to a needlestick involving HIV-infected blood at work have a 0.23% risk of becoming infected,” the CDC reports.2 “In other words, 2.3 of every 1,000 such injuries, if untreated, will result in infection.”
There have been 58 cases of confirmed occupational transmission of HIV to healthcare workers in the U.S. Of these, only one confirmed case has been reported since 1999, the CDC notes. However, there are another 150 possible cases. The numbers also likely reflect some underreporting, as case reporting of occupational HIV is voluntary. Occupational blood exposures can transmit other pathogens and diseases, including hepatitis C virus. Still, the increasing management of HIV could invite complacency and diminished urgency in adopting needle safety devices.
“We continually remind healthcare workers that HIV treatment costs $400,000, and HCV costs $70,000 — who pays for this?” Grimmond says. “Hep C is on the rise, and they are at risk from 60 different bloodborne pathogens, including new ones like Ebola and Zika.”
Another factor is the “tyranny of the urgent,” says Good. “There are so many things that have to be reported at the state and federal level in terms of patient safety goals and infection rates. [Needlestick prevention] can sort of be shifted in priority.”
Although it is unlikely that a needlestick will lead to seroconversion for HIV, HCV, or some other pathogen, the injured healthcare worker may have to wait for months in a window period before such infections are ruled out.
“It is still very stressful,” Good says. “It becomes very important and life-changing — even if all is well six months later, the surveillance was done, and they dodged a bullet. It still had an impact on their life. It made them feel less safe at work and made them change their intimacy habits. It made them go on medications that have side effects. It is not without consequence.”
An emerging trend in both EPINet and the EXPO-S.T.O.P. data is that workers are suffering splashes of blood and body fluids to unprotected eyes.
“Employees who report mucocutaneous eye exposures report wearing eye protection as little as 3% of the time,” Mitchell says.
An employee health approach cited in the AOHP data suggested looking at the problem as “the face shield is the new glove.” (See tips on prevention in this issue.)
“Probably every hospital has a policy that says if you are going to be doing something that is splash-prone, wear an eye shield,” Good says. “They leave it to the discretion of the healthcare worker to anticipate it. But they don’t anticipate it, or else they would have put an eye shield on.”
Breaking down the data, many eye splashes are being reported by workers treating patients on ventilators, she says. “Ventilators can pop apart and have body fluids aerosolized,” Good says.
Another common task linked to eye exposures is emptying drains and catheters.
“I also see splashes removing an IV,” she says. “It is not anticipated that when a needle is pulled from the arm, some blood will flick up into their eyes. Nurses don’t tend to put on eye shields for discontinuing an IV.”
Wearing eye protection when handling ventilators, drains, and IVs could eliminate about half of mucocutaneous exposures, she estimates.
“We are not telling people to always go around wearing an eye shield,” Good says. “People should look at their own data and see what their workers were doing when exposed.”
Again, it comes down to leadership, which can enact a policy for wearing eye shields for procedures identified as a splash risk.
“If that is not done, the splashes are going to keep happening because they are not anticipated,” Good says.
Financial Disclosure: Medical Writer Gary Evans, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Leslie Coplin, and Nurse Planner Kay Ball report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.