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Hospitals should plan priority HCW immunizations
Despite a shortage of this year’s influenza vaccine, hospitals are being urged to stick as closely as possible to their regular schedules for immunizing health care workers.
In early summer, the Advisory Committee on Immunization Practices sounded the first warning about problems with production of the vaccine. In July, the Centers for Disease Control and Prevention (CDC) in Atlanta announced "a substantial delay in the distribution of influenza vaccine and possibly substantially fewer total doses of vaccine for distribution than last year."1
Nonetheless, health care workers are considered a high-priority group for vaccination, along with people at high risk for complications from influenza and their close contacts.
"If there’s vaccine available, go ahead and vaccinate health care workers when you normally would," says Carolyn Buxton Bridges, MD, a medical epidemiologist in the influenza branch of CDC.
CDC also advises creating a contingency plan in the event of prolonged vaccine shortages. That might include giving priority to health care workers in intensive care, bone marrow transplant, and oncology units, says Bridges.
"In hospital wards, it is difficult to prioritize," she acknowledges. "You have post-surgical patients and any number of patients whose health status puts them in a high-risk category. Those working with the most immune-compromised may be the first people if vaccine is limited."
The shortage emerged when growing the A(H3N2) vaccine component proved more difficult than expected. Manufacturers also experienced other delays in production.
Influenza experts had hoped to boost the rate of immunization among high-risk groups. This spring, ACIP lowered the recommended age for immunization from 65 to 50 in order to capture more people with high-risk conditions.2 Only about 40% of people ages 50 to 64 with chronic conditions received the vaccine in 1997.
Among health care workers, the figures are just as bleak. Only 34% of health care workers reported receiving the influenza vaccine in the 1997 National Health Interview Survey.3 An optimal percentage would be at least 80%, says Bridges.
In an average influenza season, the virus may be linked to 20,000 to 30,000 deaths in the United States alone, with the highest rates among infants, the elderly, and those with high-risk medical conditions. A delay in administering the influenza vaccine wouldn’t necessarily impact its effectiveness, says Bridges. The CDC is recommending that influenza immunization continue throughout the 2000-2001 flu season.
"Influenza season in the U.S. generally peaks anywhere from late December to early March," she says. "The majority of flu activity may not happen until the spring. It only takes one to two weeks to give off antibody after having a flu shot."
The bottom line: Give the shots as early as you can, but still administer them if the vaccine arrives later in the fall. If you end up with extra vaccine, find out if it’s needed elsewhere in the community, advises Bridges. "What we really don’t want to see is wasting of vaccine," she says, noting that "every year, 5% to 10% of the vaccine ends up getting returned to the manufacturers unused."
1. Centers for Disease Control and Prevention. Notice to readers: Delayed supply of vaccine and adjunct ACIP influenza vaccine recommendations for the 2000-2001 influenza season. MMWR 2000; 49:619-622.
2. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and Reports April 14, 2000; 49(RR03):1-38.
3. Walker FJ, Singleton JA, Lu PJ, Strikas RA. Influenza vaccination of health care workers in the United States, 1989-1997. Infect Control Hosp Epidemiol 2000; 21:113. n
One Year Later
Hospitals still struggle to find best sharps devices
While California hospitals are still adjusting to the rapid switch to safer sharps devices, the state’s needlestick prevention law is having broad influence across the country.
One year after the California law became effective, sharps injury prevention has moved to the top of the employee health agenda. Hospitals in 13 other states are looking to the California experience to comply with similar laws, while employee health professionals in other states are reviewing their programs in anticipation of greater federal activity or other state laws.
"State legislators [around the country] could say, If they can do it, we can,’" says Susan Wilburn, RN, MPH, senior specialist for occupational safety and health at the American Nurses Association in Washington, DC. "I do believe there are components in the California legislation that are a model for everyone, including OSHA [the Occupational Safety and Health Administration]."
California’s experience offers lessons on shifting to safer products. Employee health professionals advise: Gain broad input from front-line health care workers, provide extensive training, and take the time to do it right.
Even a year after implementation, hospitals are struggling to find the best safety devices and to convince employees to activate them.
"[Employee health professionals] need to go back and re-educate after they put them in," says Cynthia Fine, RN, MSN, CIC, infection control and employee health program consultant at Catholic Healthcare West, a San Francisco-based hospital system. "They have to be real vigilant about that, and monitoring their use. Are the devices being activated? If they’re not, you have to find out why. Is it a lousy device that they don’t like, or do they not know how to activate it? [Compliance] certainly isn’t a simple process of spending the money and buying the more expensive safety device."
The California legislation transformed the way hospitals integrated new devices and investigated needlesticks. In a year and a half, the state collected information on 2,000 needlesticks at 300 facilities, mostly acute care hospitals. A report on these findings was due out in late summer 2000.
Meanwhile, hospitals accustomed to a slow process of integrating safer products were forced to meet a tight time frame. The sharps injury prevention law was passed in 1998; Cal-OSHA issued an emergency standard in December, with final rules in January. The law became fully effective on July 1, 1999.
Some hospitals faced the frustration of carefully selecting a device and then discovering it wasn’t available. "In one of my facilities, the infection control practitioner pulled the old devices out and put the safety ones in, and a month later there were shortages," says Fine. "They couldn’t get the safety devices, and they had to put the old ones back in. It confused the staff."
Force of law provides employee health boost
Other states, learning from the California experience, are providing longer implementation times in their sharps safety legislation. Manufacturers also are more prepared now for the demand for safety devices.
Despite the pressure imposed by needlestick safety laws, some employee health professionals welcomed the high profile given to the issue. "When you have the force of law, you also have some advantages in saying, This is what we need to do,’" explains Charlene M. Gliniecki, RN, MS, COHN-S, vice president of human resources at El Camino Hospital in Mountainview, CA.
With an updated bloodborne pathogen directive from the OSHA, hospitals elsewhere are facing similar questions about safer products and injury reports. OSHA inspectors, who usually come in response to a complaint, are asking to see documentation of the evaluation of safety devices and monitoring of needlesticks, as are surveyors from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations. The Health Care Worker Needlestick Prevention Act (HR 1899) is under consideration in Congress, with more than 185 co-sponsors.
"We are very attentive to each exposure, how it happened, what could be done to prevent it, and whether a safe device would have prevented it," says Gliniecki, who is also assistant clinical professor at the University of California in San Francisco. "We didn’t need a law to do this. But it moved it up on the priority list."
Efforts prioritized by risk level
Although the California law requires the widespread adoption of safety devices, Gliniecki focused her efforts to gain the greatest benefit. Her first priority was venous access to start IV lines, which carries a high risk of blood exposure.
Initial data indicate that with new safety devices, El Camino Hospital reduced its IV catheter vascular access exposures by 40%. "In a time of scarce resources, you really have to pick your battles," Gliniecki says. "We picked the IV access battle first. We wanted to make that a success as a way of supporting [other changes]."
At the same time, many facilities saw a rise in needlesticks after introducing safer devices. Some of the increase could be due to increased reporting. But employee health professionals often cited the learning curve as staff struggled to become comfortable with the products.
"As a whole, [needlesticks] have gone down, but during the time when people are using new devices they’re not familiar with, I’ve had people call me and say we’ve had more needlesticks this quarter," says Fine. "[Health care workers] may have had inservice training and then not been able to get adequate supplies, so there’s been a lag time between the inservice and actual use of the device."
The data collection sometimes points out less obvious reasons for a sudden jump in needlesticks. "There are all sorts of factors that contribute to needlestick injuries," says Wilburn. "Without the data, you can’t evaluate your situation."
At a needlestick safety workshop sponsored by the ANA, one nurse told Wilburn that the needlestick log showed an increase in three departments related to obstetrics.
"They had an architectural redesign of their postpartum care delivery to make it more hotel-like," says Wilburn. That included a recessed space in the wall for the sharps container to make it less noticeable. "One of the things they didn’t pay any attention to was how much clearance you need to give around that particular sharps container to safely put a sharp in it.
"The nurses were getting stuck because it was almost a blind alley," she says. "You couldn’t put your hand directly above it to drop it in."
The hospital is now adjusting that space, she says.
As a result of the law, California health care workers have a heightened awareness about the seriousness of needlestick injuries. In fact, hospitals have faced a rash of complaints that prompted inspections to ensure compliance with the mandates.
Even so, one of the greatest obstacles to the implementation of safety devices has been resistance to change among employees and physicians.
Fine received 700 responses to a questionnaire distributed at 47 hospitals in the Catholic Healthcare West system. Although she had hoped for an even greater response, Fine says, "I think I got a good feel for how the employees are experiencing this change."
The survey listed the devices and asked staff to circle their response: "I feel safer/I don’t feel safer" and "Effective for patient care/Interferes with patient care."
Employees also had space to write comments or to suggest a different safety device. The same device often drew strongly different opinions, with some employees saying they hated it and others lauding it.
30% of employees prefer old devices
In some cases, 70% of employees said they feel safer with the new device. But Fine is concerned about the other 30%. "They’re saying they want the old ones back, they felt safer," she says. "They’re real resistant to the change. Where do you set the level in terms of what’s adequate for employees’ [acceptance] using the devices?"
Fine is now in the process of conducting pilot studies of new devices that could be substituted for some adopted in the past year. Despite problems with implementation, Fine says the process has been positive overall.
"There were some devices people were using that they were very favorable about," she says. "I think for the most part — though people were frustrated [with the change] — they appreciated the effort we were making."
Convincing physicians to use the new devices presents a different type of challenge.
"They’re not employees," notes Gliniecki. "Even though we’re responsible for their work that may impact the health and safety of our staff, we’re not always able to get their buy-in."
For example, anesthesiologists and interventional radiologists were given the safer devices to start IVs. But in some cases, they argued, the new devices weren’t as safe for patients.
The law allows exceptions if the safety device would impact patient care, and the hospital is trying to be flexible. But Gliniecki is slowly working on adapting the physicians to the new technology.
"We pick the middle ground we can accept and work with them," she says. "We say we’re going to re-evaluate [products] in six months. I think as they have experience with this, they’ll be fine."