HIV risks remain, as needle safety goal fades

National surveillance of injuries still lacking

Eliminating needlesticks to protect health care workers from HIV and other bloodborne pathogens was once an official federal goal. The Centers for Disease Control and Prevention promoted it as a "health care challenge." More modestly, Healthy People 2010 set a measurable goal of reducing needlesticks among hospital-based health care workers by 30%.

Today, those goals have disappeared. Healthy People 2020 doesn't include a needlestick prevention goal because of the lack of a national surveillance system.

Of course, the National Institute for Occupational Safety and Health (NIOSH), the U.S. Occupational Safety and Health Administration (OSHA), and others continue to promote sharps safety. But the demise of a goal also reflects a lower profile for the continuing problem of needlesticks.

Ten years after the Needlestick Safety and Prevention Act, much work remains to be done, but the momentum has waned. After an initial dramatic decline in needlesticks, injuries have reached a plateau.

"We were more active in the area," acknowledges Teri Palermo, RN, public health adviser and coordinator of the Healthcare and Social Assistance Sector for NIOSH in Morgantown, WV. "But it doesn't mean it's something we feel is less important."

Palermo notes that the Centers for Disease Control and Prevention added needlesticks to its National Healthcare Safety Network (NHSN), an Internet-based system to collect data on hospital-acquired infections and certain types of adverse events. NIOSH is not a partner with that system, but reducing sharps injuries and improving surveillance are part of the agency's National Occupational Research Agenda. "It's still a goal to eliminate needlesticks," says Palmermo.

However, so far the NHSN has primarily focused on patient safety issues, such as health-care acquired infection. "CDC and DHQP [the Division of Health Quality and Promotion] is committed to ensuring the safety of everyone in the health care setting," says DHQP deputy director Michael Bell, MD, including patients and visitors. He notes that the safety emphasis has broadened with the success of needlestick prevention.

"You're going to see the occupational health component of NHSN continue to grow. It's going to be multidimensional," he says.

Bell also notes that prevention of bloodborne pathogen exposures will be part of the update of the guideline on infection control for health care personnel that is currently underway.

Meanwhile, NIOSH no longer is receiving earmarked funding for preventing HIV and other occupational bloodborne pathogen risks, says Ahmed Gomaa, MD, ScD, MSPH, medical officer in NIOSH's Division of Surveillance Hazard Evaluation and Health Studies. NIOSH has continued publishing documents on sharps injury prevention but new areas of research lack funding, he says. "We definitely are not finished yet. We have a lot of work to do," he says.

For example, Gomaa would like to see research on design changes in the operating room environment that could reduce sharps injury risk.

Employee health professionals also would like to learn more about effective ways to further reduce needlesticks. "Our concern is that although the numbers have decreased, we're still seeing significant exposures with the safety devices," says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, community liaison and past executive president of the Association of Occupational Health Professionals in Healthcare in Warrendale, PA, and employee health coordinator at Western Pennsylvania Hospital in Pittsburgh. "We would still see value in continuing research efforts to mitigate those risks and to continue to reduce the injuries."

Research also is needed to determine why safety devices often aren't activated, says Jane Perry, MA, associate director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville. "There's definitely still room for growth and improvement of device design," she says.

OSHA: We still care about needlesticks

In the initial years after passage of the Needlestick Safety and Prevention Act, enforcement actions rose. It is consistently one of the most frequently cited standards in hospital inspections. But recently, citations have declined to earlier levels.

In 2002, OSHA issued 128 citations to hospitals under the bloodborne pathogens standard. In 2009, there were 81 such citations. The violations were common ones: Failure to have an exposure control plan or to update it annually, or failure to have appropriate safety devices.

OSHA will continue to cite employers under the standard, says Dionne Williams, MPH, a senior industrial hygienist with OSHA. "Bloodborne pathogens has been and will continue to be something of interest to OSHA," she says, noting that OSHA is in the "pre-rule" stage for an infectious disease standard and injury and illness prevention program standard, both of which could interconnect with efforts to reduce bloodborne pathogen exposure.

This summer, OSHA solicited comments in a review of the Bloodborne Pathogens Standard. Many comments supported the standard, with suggestions for small changes. The American College of Occupational and Environmental Medicine called the standard "probably one of the most cogent and successful OSHA regulations seen over the past 40 years."

The International Healthcare Worker Safety Center urged OSHA not to weaken the standard. More attention is needed in the operating room and in alternate settings, such as home health care, where the health care workforce is projected to increase substantially, Perry told AA. Little data is available on sharps injuries that occur in physicians' offices, outpatient centers, home health, or other locations, she says.

Even hospitals have room for improvement. While safety devices have almost completely replaced conventional ones in some categories, there are still gaps in the availability of safety technology, Perry notes. Hospitals need to make an effort to locate safety devices as new products become available, she says.

"A lot of hospitals have gotten the structure in place for exemptions to the requirement to use safety. Is that just going to continue from year to year, giving these exemptions?" she says.

New safety designs needed

Numbers tell the good-news, bad-news story of sharps injuries in hospitals. Injuries declined swiftly as hospitals adopted safety devices, and from 1993 to 2006, needlesticks had declined by about 32%, according to EPINet surveillance data from the International Healthcare Worker Safety Center.

But in recent years, there has been little further reduction in sharps injuries. For example, Texas public hospitals and other public health care facilities report needlesticks annually. The tally in 2008 was virtually the same as in 2004.

In Massachusetts, where all hospitals must report sharps injury data annually, needlesticks declined from 3,413 in 2002 to 3,126 in 2008 — a reduction of 8%. Hypodermic needles and syringes continued to account for 31% of injuries, and one-quarter of those injuries (27%) occurred with conventional needles — even though safety syringes are readily available and widely used.

"The occurrence of injuries with [safety-engineered sharps injury prevention features] raises important questions about the effectiveness of the current technology used to prevent sharps injuries," Angela Laramie, MPH, epidemiologist with the Sharps Injury Surveillance Project in the Massachusetts Department of Public Health in Boston, wrote in comments to OSHA. "The extent to which injuries involving [safety devices] are due to flaws in the design of the devices or the lack of experience and training in using these newer devices needs to be examined."

Too often, employers are not fully involving frontline workers in the evaluation and selection of safety devices, as required by the OSHA standard, says June M. Fisher, MD, director of the TDICT (Training for Development of Innovative Control Technologies) Project in San Francisco.

"[With that process,] you will more than likely pick the appropriate tool," says Fisher. "Not all the devices will suffice for everybody."

Employees also need sufficient opportunity for training, she says. If health care workers are comfortable with the devices they're using, they're more likely to activate the safety features, she says.

Of course, the best solution lies with new technologies that eliminate the sharp entirely (such as nasal administration of vaccines) or use a passive safety feature that does not require activation by the user, Fisher says.

Preventing sharps injuries must be a sustained, ongoing effort because technology can never completely remove the risk, says Perry.

"We here at the center never thought that eliminating needlesticks was necessarily a realistic goal, given the technology we currently have," she says. "As long as you have a sharp object and it's being used on patients in unpredictable situations, people will still get stuck."