By Patricia J. Beilke, MA, RN; Cheryl Reiniger, RHIT; Chris Ames, MLT, ASCP, Vicki Sellner, LPN; Cheryl Baumann, RN; Kris Pendergast; and Michelle Lamecker, RN
The Needlestick Safety and Prevention Act became Public Law 106-430 on November 6, 2000. In 2001, in response to the Needlestick Safety and Prevention Act, OSHA revised the Bloodborne Pathogens Standard (29 CFR 1910.1030) to contain language designed to prevent needlestick injuries to healthcare workers. In 2013, publications are still full of advice on preventing needlestick injuries for healthcare workers.
This is the story of the efforts of one rural medical center to use “engineering and work practice controls to eliminate or minimize employee exposure to bloodborne pathogens,” per OSHA's Bloodborne Pathogens Standard.
The Sleepy Eye Medical Center (SEMC) is a small critical access hospital and clinic in rural southwestern Minnesota. The medical center consists of an acute-care hospital and attached clinic. It is a certified Level Four Trauma Center, provides medical and general surgical services as well as obstetrical services, physical therapy, and swing bed services. With about 110 total employees it provides care on average for more than 1,100 inpatient days of care, 1,100 outpatient visits and 500 swing-bed days of care annually as well as the diagnostic procedures to go with that.
The medical center tracks both sharps injuries (clean devices) and exposure incidents (used devices) through the infection prevention surveillance program. In 2009 when there were five injuries, and a total of 19 injuries from 2003 to 2010. The newly reorganized safety team recognized this was an unacceptable level of injuries for a 110-person staff and decided to spin off a sharps safety work group. The assignment for the group was to reduce the number of sharps injuries occurring annually.
The sharps safety team consists of a representative from the laboratory, one from the clinic nursing staff, one from the OR/CSR staff, and one person from hospital nursing. Also part of the team was the safety/risk manager, and the director of materials management who was in charge of purchasing. Leadership for the team was delegated to the infection preventionist.
Since everyone knew the mandate (too many injuries) and why it was given, there was only one agenda item for the first meeting. That was “Where do we start?” Fortunately in the pre-meeting research, one of the team had come across the CDC resource called “Workbook for designing, implementing and evaluating a sharps injury prevention program.” Being a very small facility, this was not only a wonderful resource, but in many ways, “overkill” and had to be modified to meet our needs. It was important as it gave some concrete activities that would support engagement in the work ahead.
The first action was to do a baseline sharps injury profile. This looked at past data to identify:
• How many injuries were occurring,
• Who was being injured (categories of workers),
• Where were the injuries occurring (i.e., ED, OR, delivery room, etc.
• What devices had been involved in the injuries, and
• What work practices were being performed when injuries occurred?
While this told us some things, the low data numbers weren’t as useful for setting priorities as it likely would have been from a larger facility with more strength of numbers. It left the question of where we should go next hanging in the air.
We then completed a sharps risk analysis by having team members from OR, Clinic, Lab and Hospital Inpatient areas answer the following questions:
• Do your department policies list using safety engineered devices wherever possible?
• Do your department policies spell out the expectation that safety engineered devises are to be used according to manufacturer’s directions?
• Does your department orientation address safe sharps work practices?
• Are sharps containers in your area immediately adjacent to where you use sharps?
• Has sharps safety been an agenda item at a department meeting in the last: three months? six months? one year?
The final question on the risk analysis was “Ask three team members in your department where/how the next sharps injury will occur in your department?” The risk analysis was very useful and gave us directions specific to the needs and perceived risk of the staff. An action plan was drawn from these needs.
Though the team was making progress, there was a feeling that it wasn’t fast or far enough to get us where we really needed to go. We needed to specifically address the OSHA standard which states, “engineering or work practice controls shall be used to eliminate or minimize employee exposure.” That 2001 revision defines engineering controls as “controls (e.g., sharps disposal containers, self sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.”
With this in mind, the team decided we needed to look at our sharps devices themselves. We went to the store room to look at what we were purchasing and stocking. What we found was an entire shelf of standard (unattached) needles. We realized we had very few safety engineered devices in stock.
This trip to the storeroom allowed for the development of a table that listed all the unattached needles in the inventory. Once that information was gathered, each team member took the list back to their work areas with the questions:
1. Are we currently using this device?
2. What are we using it for?
3. How often do we use it?
4. Could this device be placed with a safety engineered device if one is available?
5. If nothing else could replace this device, describe why. (Physician preference alone is not a valid reason.)
Through this process we identified that many of the needle supplies we were stocking were duplicates or not necessary.
Next, we worked with the materials manager to find safety engineered replacements for the devices we would need to continue stocking. Samples of safety engineered devices were obtained and trialed by the employees (including physicians) that would be using them. The employees then selected the products that worked best for them.
Sometimes when departments were using two different but similar devices, it was necessary to get the departments to work together to decide that they could use the same device. This allowed us to eliminate the similar device from the inventory. Through this painstaking process of closely analyzing each device and how it was being used, we were able to eliminate some devices altogether and to replace others with safety engineered devices.
In January 2010 there were 15 varieties of unattached injection needles stocked in the store room. Ten of those 15 were not safety engineered. In January 2011 only four unattached injection needles were not safety-engineered. Syringes with sheaths that pull down over the needle are now used with those needles to provide the safety shield.
As we replaced inventory in the store room, the work of the team was really beginning on their units. The team had to work very closely with the staff in their departments to find all the places that sharps were stocked. We found sharps stocked everywhere in an attempt to have the tools close to the work. They were stocked as individual items and in “sets” of equipment put together for particular procedures or purposes.
The unit restocking process had to be addressed also. Staff would go to look for what they were familiar with seeing in a certain drawer, or using for a particular task. Old (unsafe) inventory had to be removed and made inaccessible or it would be placed back in circulation. It was not possible to accomplish the change by “phasing out” or “using up” the unsafe inventory. A process of intense monitoring and just-in-time teaching took place to get the changes complete and make them stick. The materials manager was critical in this change as the request to order the unsafe supplies continued for weeks. These requests were intercepted by the materials manager and again, the team would go back to provide more teaching while the proper safety engineered devices were ordered.
An education program using staged pictures to portray unsafe work practices was developed. Each picture shows a staff member or device in an unsafe situation. The situations included things like a trash bin underneath the wall mounted sharps disposal container; an overfull sharps container, or a worker recapping a needle after an injection. Staff members were then asked to identify the “risk” or unsafe situation portrayed in the photo. This was well received and stimulated a lot of productive discussion of work practices
The success of these intense and detailed interventions has been beyond expectations. SEMC has had no reported exposure incidents or sharps injuries since October 2010, the year this initiative began. The interventions in place to sustain the gain include:
• The key role of materials management in seeing that only approved safety engineered devices are ordered and brought into the facility.
• Policies that restrict samples and unrequested products brought in for “trial” without review by a team that evaluates products for qualities like safety.
• Sharps safety is included in orientation for all newly hired employees regardless of department.
• Emphasis on the importance of reporting sharps injuries even when it is not an exposure incident as this is important for assessment of the safety of the device itself, and
• Asking staff “Where will the next sharps injury occur in your area?” Then evaluating the risk.
This small rural medical center was able to significantly reduce sharps injuries and exposure incidents through a series of interventions, guided by the CDC Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program. (Available at the CDC web link listed below)
The key interventions first centered on understanding the current state of both work practices and devices through staff surveys and a sharps risk analysis. Significant gains were made by taking control of the device inventory and ordering processes. Worker engagement was gained through the device trial and evaluation process as unsafe devices were eliminated and replaced by safety engineered devices. Education interventions were provided along the way. Just-in-time training, individualized training and counseling, and large group educational activities to support safe work practices were all used. The gains have been sustained for two-and-one-half years with no sharps injuries or exposure incidents reported. Each day without an injury is a new success!