EPINet, ICPs respond to OSHA needlestick request

Surveillance network urges adoption of devices

The most well-established surveillance network on needlestick injuries and exposure prevention devices in the United States has come out in favor of a "complete transition" from conventional sharps to safety devices, Hospital Infection Control has learned.

The Charlottesville, VA-based International Healthcare Worker Safety Center at the University of Virginia takes this position in comments to the Occupational Safety and Health Administration. With increasing calls for the required use of needle-safety devices designed to prevent blood exposures to health care workers, OSHA recently published a request for information (RFI) that could be a prelude to regulatory action.1 (See Hospital Infection Control, November 1998, pp. 164-165.)

"The [center] is in favor of measures that would result in a complete transition from conventional to safety devices in the U.S. health care workplace," the comments state. "We very much hope that this RFI will result in OSHA’s taking concrete steps to bring this about, thus creating a safer work environment for American health care workers in every state."

The comments also provide a detailed overview of the needlestick problem and implementation of devices based on data compiled from approximately 70 hospitals in the Exposure Prevention Information Network (EPINet), the largest data base of its kind in the United States. Based on 1997 EPINet data, 78% of injuries from hollow-bore needles fall into a "potentially preventable" category.

"This figure clearly indicates that the health care industry is far from achieving the best possible level of injury reduction among health care workers," the comments state. "At the Center, we believe a national goal must be to rapidly implement effective protective technology which, like a universal vaccine, can prevent transmission of all bloodborne pathogens. With more than 1,500 patents issued in the last decade for devices designed to prevent needlesticks, safety devices are now available in every major device category."

Needleless IV systems have found the widest acceptance, with more than 65% of hospitals purchasing this equipment. But the device categories that pose the greatest risk for transmission of bloodborne pathogens lag far behind this mark, with only 28% of hospitals switching to safer devices for IV catheters and less than 10% of hospitals switching for blood-drawing needles, the center notes in its comments.

In addition, EPINet data underscore the following statistical highlights:

• The average rate of reported sharp-object injuries is 30 injuries per 100 occupied hospital beds per year.

• The total annual percutaneous and mucocutaneous exposures to blood or at-risk biological substances in the United States, based on 1996 EPINet data, was 786,885.

• Before the widespread implementation of needleless and protected-needle IV systems, 26% of needlesticks involved IV infusion equipment with needles. Now they account for only 3%.

• A shielded stylet safety IV catheter reduced IV catheter-related needlesticks by 83%.

• Injuries associated with recapping needles have declined dramatically over the past decade, from about 25% of hollow-bore needle injuries to about 4% today.

• Overall, 25% of percutaneous injuries fall into the high-risk category (injuries from blood-filled needles). Of these, about 74% are related to blood drawing, and 26% to IV catheter placement.

In additional comments gleaned from the OSHA docket on the needlestick prevention RFI, individual infection control professionals detailed their experiences with the devices.

Kathy M. Henderson, RN, employee health coordinator at Columbia Augusta (GA) Medical Center, said she received approval recently to implement new engineering controls after implementing some needleless devices three years ago. She underscored the variety of sharps injuries that can occur in telling OSHA that the facility recorded 28 needlesticks in 1997 and 22 as of Nov. 20, 1998. Those injuries involved needles, knife blades, patient’s staples, scissors, a glass slide, and a small sliver of glass from a laboratory tube.

Overcoming financial implications

Henderson and colleagues have instituted new engineering controls in the form of safety needles and phlebotomy devices. However, she said the effort took a "labor-intensive" year of presentations to various hospital committees.

"I feel that the most difficult obstacle to overcome is the financial aspect associated with implementation," she states in the OSHA comments. "These devices are considerably more expensive to purchase and until you implement them you can’t prove that savings will be recognized in treatment cost for post exposure. It’s difficult to prove . . . that you’re trying to be proactive and avoid the extravagant cost that can result from an HIV seroconversion or a hepatitis C [virus] seroconversion."

Success can be achieved, however, through perseverance, use of objective data, and having health care providers involved in the financial decisions, she says. After educating employees about the use of safety devices, continued noncompliance should result in disciplinary action, she adds.

In additional ICP comments, Bridget Farrell, RN, director of infection control and employee health services at Burdette Tomlin Memorial Hospital in Cape May Court House, NJ, told OSHA that a significant reduction of exposures occurred after the implementation of a safety-designed IV catheter system and a secondary IV "piggy-back" protection system. Requests for all new products are submitted to a hospitalwide products committee that has multidisciplinary representation, she explained.

"Very high product costs may delay the decision to purchase the products," she states in the comments. "Historically, the purchase of costly products is more likely to occur if [the] product is already part of a group purchasing contract."

Staff input in the choice of products is important because the device must be readily available and user-friendly for successful implementation, she adds. Initial and follow-up education is the key to acceptance and use, Farrell notes.

"It takes longer initially to deliver patient care when using a number of safety devices," she told OSHA. "Over time, this does not have a negative impact once [the] learning curve is achieved."

Cost remains an important issue, and assessing the compatibility of new products to existing systems adds another challenging dimension to the decision-making process, she told OSHA.

"The arguments for prevention, the right thing to do, and the potential for the acquisition of serious illness or death are incalculable," Farrell states in the comments. "It is difficult to translate these risks into a measurable bottom line that facilitates the hard financial decisions that must be made in health care today."

Doris Wuensche, RN, CIC, director of infection control at Citizens Medical Center in Victoria, TX, reports favorable results following the purchase of safety-designed lancets for fingerstick blood sampling.

"This was our most stunning success and occurred about five or six years ago," she states in the comments to OSHA. "We have only had one or two exposures from this source in the last five or six years, and both of those were from improper use of equipment."

But every new device that is adopted requires a "maximum effort" to get it accepted because most require changes in technique, she adds. In some cases workers have refused to use the safety equipment, and may continue to do so as long as conventional alternatives are available, she says.

"Prices on the safety devices must come down before they can be universally used; under the current cost-containment climate, nobody can afford everything they need," she says.


1. Occupational Safety and Health Administration. Occupational Exposure to Bloodborne Pathogens: Request for Information. 63 Fed Reg 48,250-48,252 (Sept. 9, 1998.)