OSHA aims to reduce sharps injuries among health care workers
Agency trails California in focusing on safer needle devices
Hospital employee health professionals have until Dec. 8 to respond to the U.S. Occupational Safety and Health Admini stration’s (OSHA) request for information (RFI) on engineering and work practice controls that successfully eliminate or minimize contaminated sharps injuries incurred by health care workers on the job.
However, while OSHA touts the RFI as a first step in directly addressing the problem of disease-transmitting needlesticks among workers, other advocates for HCW safety say OSHA already has the information it needs to protect workers from percutaneous injuries (PIs). They also point out that the federal agency lags behind California OSHA, which has taken the lead in revising its state bloodborne pathogens standard to require the use of safer needle devices whenever possible.
Federal OSHA’s RFI, published recently in the Federal Register, states that "percutaneous injuries continue to be a concern in work settings where employees are exposed to bloodborne pathogens. [OSHA] is considering possible actions that it can undertake to assist in addressing this issue. . . . The information received in response to this notice will be carefully reviewed and will assist OSHA in determining effective approaches to reducing percutaneous injury rates and what role the agency may have in these approaches."1
OSHA estimates the number of sharps injuries incurred by U.S. HCWs at 600,000 annually, but occupational health experts generally recognize that those numbers are vastly underreported. PIs can cause serious illness or death from bloodborne pathogens such as HIV and hepatitis B and C. Since promulgation of the federal bloodborne patho gens standard in 1991, which requires hospitals and other health care facilities to offer hepatitis B vaccine to employees, HBV infections among HCWs declined from about 5,000 new cases that year to about 800 new infections in 1995, according to OSHA. The incidence rate of hepatitis B infections among HCWs is now lower than the incidence rate for the general U.S. population.
However, PIs continue to be a major occupational health concern. The rapid development of safer needle devices that could prevent or minimize bloodborne pathogens exposures has spurred HCW unions and other concerned groups and individuals to call for a change in the bloodborne pathogens standard that would require health care facilities to purchase, evaluate, and use the new technologies.
Systematic’ approach planned
Whether the RFI will lead to a revised standard depends upon information submitted to the agency, OSHA officials say. At a recent HCW safety conference focusing on bloodborne patho gens exposures, Charles N. Jeffress, OSHA’s assistant secretary of labor for occupational safety and health, announced the agency’s commitment to reducing needlesticks. (See related story, p. 133.) The RFI is the first step in OSHA’s plan to address the problem systematically, he said.
In releasing the request, Jeffress noted that OSHA has received numerous suggestions for reducing needlestick injuries. "To determine the best strategies, we must begin by gathering information systematically to find out what measures are effective in the workplace," he says.
The RFI specifically seeks information on strategies that have been implemented successfully in the work environment for eliminating or minimizing contaminated sharps injuries, and particularly on the use of safer medical devices designed to limit injury risks. The phrase "safer medical devices" means "the wide variety of implements designed to reduce the risk of needlesticks and other percutaneous injuries through such measures as substitution (as in the use of a blunt cannula with a prepierced septum for intravenous administration of medication), modification of the device to reduce the hazard (as with a blunt suture needle), or incorporation of safety features (as with a retractable-needle syringe)," the RFI states.
OSHA also is interested in successful PI prevention programs that integrate the use of safer medical devices, safer work practices, elimination of needles and other sharps in certain instances and procedures, focused intervention in high-injury areas, specialized training, and other elements. (See specific questions, p. 131.)
Elise Handelman, RN, MEd, COHN-S, director of OSHA’s office of occupational health nursing, says the agency is trying to ascertain the prevalence of needlesticks. "One of the big problems is underreporting," she says. "We believe needlesticks are widespread, and we’re trying to get data on that."
In requesting information on preventing PIs, OSHA is "casting a wide net," Handelman explains. "We want to know what works. The question we’re asking is, What’s the best way to approach reducing needlesticks? Is it [safer] devices? Is it getting employee input? Is it making sure employees are trained properly? Is it redesigning work processes to eliminate the need for needles?’ This is not an issue for which we have a lot of hard research, so we’re trying to get more data on what works."
Has OSHA heard it all?
However, international sharps safety expert Janine Jagger, PhD, MPH, says OSHA already has all the information it needs to take action on promoting safer device technologies to prevent needlesticks, but thus far has failed to do so.
"I’ve already said a thousand times what I’ve had to say," says Jagger, director of the Interna tional Health Care Worker Safety Research and Resource Center at the University of Virginia in Charlottesville. Jagger developed and coordinates the Exposure Prevention and Information Network (EPINet) data collection system for identifying and assessing injury-causing needle and sharps devices. "I don’t have anything new to provide to OSHA that’s not available to them already. I don’t think anyone will have anything to say that OSHA hasn’t heard already."
OSHA could have a significant impact on the rapid implementation of safety devices in health care facilities by looking for those devices during inspections, but "so far they haven’t done it," she states. A change in the agency’s inspection criteria would go a long way toward getting hospitals to recognize that implementation of safety devices "is not just a mere product choice like any other."
If the agency’s RFI leads to incorporating additional inspection criteria aimed specifically at safer devices, then the effort will be worthwhile, she adds.
"Asking for information is one thing, but doing something with it is entirely different," Jagger says. "OSHA has done good things for health care worker safety in general but has done very little in terms of promoting safer technologies to prevent needlesticks. They can make a big difference here, and I view this announcement as positive. But I won’t view it optimistically until the first sign of turning information into action."
Handelman says OSHA could take any of several actions, including changes in the bloodborne pathogens standard, changes in enforcement, changes in outreach, or changes in training for compliance officers.
"The plan will be based on the information we get," she says.
Whatever course of action OSHA eventually chooses, the federal agency will be lagging behind California OSHA (CalOSHA), which presently is in the final stages of revising its state bloodborne pathogens standard to mandate the use of new technology designed to prevent sharps injuries.
CalOSHA’s actions have been spurred in no small part by passage of a state bill last August — the first such state law in the nation — that requires health care employers to make safer needle devices available to HCWs. At press time for this issue of Hospital Employee Health, it was not known whether California Gov. Pete Wilson would sign or veto the bill.
Nevertheless, Len Welsh, JD, MPH, special counsel to CalOSHA, tells HEH that the legislation "basically tells us to do what we’re already doing, which is adopt a standard like the one we’re already working on."
If the bill becomes law, it would set an Aug. 1, 1999, deadline for adoption of a revised standard, but Welsh says he’s confident that CalOSHA will have a new standard on the books well before that date. Action on a revised standard was accelerated "due to a tremendous outpouring of interest in having this attended to expeditiously," he says.
A state advisory board of labor, management, and infection control professionals came to an "unusual consensus that enabled us to move forward a lot more rapidly than we usually manage to do," he explains. Similar to the federal standard after which it was modeled, the present California standard merely mentions self-sheathing needles as an example of an engineering control for preventing injuries.
"It leaves everyone in a quandary as to what they’re supposed to do," Welsh says.
The final draft of a revised state standard includes a three-tiered requirement for the use of needleless systems where available, needle devices with engineered sharps injury protection, and a "catch-all" category for non-needle sharps, such as capillary tubes, with engineered protection.
Welsh says four exceptions to the requirements are included, mainly to assuage industry concerns. The exceptions are: lack of market availability of devices; patient safety considerations; safety performance (when a device marketed for safety doesn’t perform as expected); and circumstances in which it is not known whether a device works better or worse at reducing exposure incidents.
In addition to the safer technology requirements, the revised standard will include more detailed criteria for recording percutaneous injury incidents and data about devices that were used.
Welsh says California is the first state to make substantial amendments to its bloodborne patho gens standard. He adds that federal OSHA seems to be headed in the same direction, "but they’re going a lot more slowly."
Some activists wonder why CalOSHA is doing more than its federal counterpart to protect HCWs.
"I’m glad there is some life in these federal agencies when it comes to protecting workers, but why is California doing so much more?" asks William K. Borwegen, MPH, director of health and safety for the Washington, DC-based Service Employees International Union (SEIU), which represents about 600,000 HCWs nationwide. "The FDA [Food and Drug Administration] has approved some 250 safer products, and lives could be saved if employers bought this newer generation of devices."
For nearly a decade, SEIU has been pushing CalOSHA for stronger state regulations to protect HCWs. On the federal level, the union has campaigned for OSHA to cite employers for failing to evaluate safer devices and would like to see changes in the federal bloodborne pathogens standard similar to those planned in California.
"We applaud [federal] OSHA’s new leadership, but this is just a baby step in the right direction," Borwegen says. "Hopefully, OSHA is just setting the stage here so they have a legal basis for being more aggressive. Health care workers in the other 49 states face the same hazards health care workers in California face. Lives could be saved by buying these safer devices."
[Editor’s note: Comments on the RFI should be submitted on or before Dec. 8 in quadruplicate or one original (hard copy) and one diskette in WordPerfect 5.0, 5.1, 6.0, 6.1, 7.0, 8.0, or ASCII to: Docket Officer, Docket No. H370A, Room N-2625, U.S. Department of Labor, 200 Constitution Ave. NW, Washington, DC 20210. Telephone: (202) 219-7894.
Comments of 10 pages or less may be transmitted by fax to (202) 219-5046, provided the original and three copies are sent to the Docket Office thereafter.
Comments also may be submitted electronically through OSHA’s Internet site at: http://www.osha-slc.gov/html/needle-form.html. Information such as studies and journal articles cannot be attached to the electronic response and must be submitted in quadruplicate to the above address. Those attachments must clearly identify the respondent’s electronic submission by name, date, and subject.
For further information, contact Bonnie Friedman, director, OSHA Office of Public Affairs, at (202) 219-8148.
In addition to the Federal Register, the RFI may be accessed on the OSHA Internet site at: http://www.osha.gov. Click on "Federal Register," then "date of publication" (Sept. 9), then "1998."]
1. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: Request for information. 63 Fed Reg 48,250-48,252 (Sept. 9, 1998).