Watch out! OSHA may crack down on reuse of blood tube holders

Union decries practice as common but dangerous’

The common practice of reusing blood tube holders violates U.S. Occupational Safety and Health Administration (OSHA) regulations and is an issue under review by the agency, Hospital Employee Health has learned.

The California Division of Occupational Safety and Health (Cal-OSHA) recently cited the Kaiser Permanente Los Angeles Medical Center for reuse of tube holders, and Cal-OSHA had previously cited Seton Medical Center in Daly City for that practice. Although federal OSHA inspectors have not issued citations related to the practice, both the 1991 bloodborne pathogens standard and the 1999 updated compliance directive prohibit the practice, a senior OSHA official says.

The removal of tube holders is prohibited even if the health care worker uses a device, such as a gripping mechanism on a sharps container, Cal-OSHA and OSHA officials say. "We’re working with [the National Institute for Occupational Safety and Health] and the [Food and Drug Administration] on solidifying a policy on that issue," a senior OSHA official says. "The standard is clear that needles must not be removed unless it’s medically indicated by a procedure."

Because OSHA has not been citing hospitals for the practice, some may erroneously believe that the removal of tube holders using mechanical devices is allowed. "It’s apparent that it’s been a misinterpretation of the standard," the OSHA official tells HEH.

Removing the tube holder exposes the "back end" of the blood-filled needle, creating the potential for a needlestick. That risk exists regardless of the removal method used, officials say. "Whenever you remove a needle, there’s a potential for needlesticks," says Len Welsh, special counsel for regulatory development at Cal-OSHA. "That’s the presumption in the regulation."

The International Health Care Worker Safety Center at the University of Virginia in Charlottesville, a leader in the shift to safer devices, likewise advises hospitals not to reuse tube holders. The center’s publication, Advances in Exposure Prevention, featured an article on a home health nurse who became infected with hepatitis C from a needlestick that occurred when she removed a reusable blood tube holder.

"The trend among device manufacturers is toward phasing out reusable blood tube holders," the center commented. "By instructing employees not to reuse holders, hospital administrators will help reduce the number of preventable sharps injuries and improve safety in the health care workplace."

Shift could impact waste disposal

Still, a shift to single-use tube holders would have a significant impact on hospitals around the country because their reuse is so commonplace. One needlestick expert estimated that the cost of additional or larger disposal containers alone would cost $25 million nationwide.

While individual tube holders may cost only a few cents, the item is used in massive quantities at hospitals around the country. And the disposal of the additional units has environmental and other ramifications.

"This is a difficult issue because the risk from back-end needles is relatively remote," says Gina Pugliese, RN, MS, director of the Premier Safety Institute of Premier Inc., a health care alliance based in Chicago. "Hospitals have to balance the whole spectrum of issues, including worker safety, patient safety, cost, and the impact on the environment."

For example, Sewickly (PA) Valley Hospital is currently considering the tube-holder issue in its lab, says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, employee health nurse practitioner. As executive president of the Association of Occupational Health Professionals, she is aware of the broader impact of halting tube-holder removal. "You’re going to have a phenomenal increase in the use of those devices [nationwide]," she says. "They’re fairly bulky, so if you have to dispose of them, you’re going to have the cost associated with that."

Disposal containers could become filled more quickly, which means they would need more frequent emptying. Overfilled sharps disposal containers would be a needlestick risk, Gruden notes.

Those are exactly the issues that Seton Medical Center faced when the hospital was cited by Cal-OSHA in 1999 for removal of the tube holders. With a switch to single-use devices, the hospital installed larger sharps containers in patient rooms. The cost of additional tube holders was offset by a price reduction the Catholic Healthcare West hospital system received from the vendor, according to Cynthia Fine, RN, MSN, CIC, infection control and employee health manager at Catholic Healthcare West in Oakland, CA.

"I think the fact that we’ve been able to [make the switch] successfully in California and at other hospitals around the United States means it is doable," she says. "The big issue for me is increased waste. I don’t see any way to prevent that."

Meanwhile, unions that represent health care workers have begun to focus on the reuse of tube holders. Bill Borwegen, MPH, occupational health and safety director of the Service Employees International Union in Washington, DC, says the union will continue to file complaints on the issue. "This may be common, but it’s a dangerous practice," he says.

Hospitals may find themselves hard-pressed to justify it. At Seton, Cal-OSHA reduced the fine because inspectors had overlooked the practice for years, but officials would not dismiss the citation, recalls Fine. Ultimately, halting the removal of tube holders is simply the right thing to do, she says. "If you look at the big picture, if we’re preventing needlesticks, that’s what we need to do."