Maintaining a Sharps Safety Focus Maintaining a Sharps Safety Focus
By Kris Ellis
The International Healthcare Worker Safety Center at the University of Virginia recently reported that data collected from 48 U.S. healthcare facilities in 2003 via the EPINet surveillance program showed that participating hospitals experienced 23.87 percutaneous injuries (PIs) per 100 occupied beds.1 The report notes that great variation existed between the facilities involved from a zero PI rate at six facilities to a rate of more than 50 per 100 beds at two facilities. Statistics such as these underscore the fact that sharps safety is still a significant issue in some areas.
While efforts on the part of clinicians, educators, manufacturers, and legislators to wipe out sharps injuries have undoubtedly made hospitals safer places, for many, there is much work yet to be done.
Step one is to get the right devices in place, says Gina Pugliese, RN, MS, vice president, Safety Institute at Premier, Inc. To do that you need input from the workers who are going to be using those devices so they can choose devices that they like. If you get them involved in the process, which is what the Occupational Safety and Health Administration (OSHA) requirement is, youll get buy-in from the front lines. Thats really the key.
If your front-line workers do not like what theyre using, you have a problem, Pugliese continues. If you choose a product and your front-line workers find that they dont like it, you need to have another evaluation and find something they do like, which is why you have an annual review, because not everything will necessarily work after you implement it it might be too complicated, it might not work in the kind of disposal units you have, peoples hand size might be an issue, the design might have changed slightly from the original, the safety feature might not be reliable, it doesnt fit with other devices easily, for example there are all kinds of potential issues. You have to have an ongoing review of what youre doing.
Pugliese explains that only front-line workers can evaluate device nuances that must be accounted for. There are so many different factors you can consider when you choose a device and thats why theres such a variation in selection the size of the hand, whether theyre right-handed or left-handed, whether theres an audible change like a click or sound, or a color change, how complicated they are to use, etc.
Incorporating safety devices wherever possible is a vital step for all facilities, but it cannot guarantee an injury-free environment. Data from the International Healthcare Worker Safety Center report showed that of the 1,708 total injuries described, 340 occurred when a safety feature was not activated.2 If you only have sharps safety devices, are they using them correctly? Pugliese questions. In other words, are they activating the safety feature, or are they throwing them in the sharps safety disposal unit without activating them? A lot of the needlesticks are happening because the devices are not activated. Workers need to be aware of the risks when they do not activate the safety mechanism. Some workers choose safety devices that activate in a passive manner, that is, the safety mechanism automatically works as part of the procedure, such as a retractable needlesyringe. With passive activation of the safety feature, you do not have to rely on worker compliance. However, there is a range of technology out there to choose from, both active and passive, and the final decision relies on what is preferred by the worker.
Very frequently, and most unfortunately, a good number of injuries occur with the use of safety devices, because healthcare workers didnt activate the device, says Rita McCormick, RN, CIC, infection control practitioner at University of Wisconsin Hospital and Clinics. That really needs to be underscored, because facilities clearly have recognized that theyre obligated to provide safety for the worker and everything is a two-way street workers have obligations, and employees have obligations. In most places, employers have embraced their obligation to provide safety for their workers quite well. It boggles my mind that people simply decide to not use something that was purchased at sometimes as much as three times the cost, and they get stuck with it.
Pugliese also points out that bloodborne pathogens can affect patients as well as workers. If you choose a sharps safety device to use in the OR, youre protecting yourself as a worker from the blood of the patient, and if you happen to stick yourself during surgery and a drop of blood goes into the patient, then youve exposed the patient to your blood, so in the OR, sharps safety is for both the patient and the worker.
The Educational Challenge
The process of educating and informing healthcare workers about the importance of preventing bloodborne pathogen exposure is a continual effort for many infection control practitioners. If you really look at the principles of adult education, people want information when its relevant to them, so you look for teaching moments, McCormick explains.
There is no better teaching moment than when the person is being worked up following a needlestick injury. From my perspective, although some people dispute whether there is time for this to always be done, I think its worthwhile for the employee health people who do the post-exposure follow-up to try and determine exactly what happened when this occurred, and if they were aware of how the device works, because sometimes they might have been taught one particular device, know it backwards and forwards, and they come to a new hospital and that device is no longer there and they need to learn new devices and so on. Is education adequate at that time?
Devoting sufficient time and resources for effective training and education is a necessity for new devices. Not all devices are intuitive, McCormick cautions. Its hard to get everybody on every shift as well. As more and more safety devices come into the workplace, youll see more injuries that occur even when a safety device is in use thats the nature of the beast.
Then you have to examine, Why are we seeing injuries with this device? If theyre not activating it, thats pretty self-explanatory, but if they indicate on the incident report that they had trouble activating it, or they thought it was activated when it actually wasnt, then youve got to go back and see if theres a better device on the market.
The method by which a device is activated can become an issue as well. Most of the time when the manufacturer made a safety device, they had in mind a preferred way of activating it, McCormick continues. When people make modifications to that, they get into trouble. For instance, at her facility a butterfly needle is being phased out and replaced. It was designed by the company to be changed using a one-handed method, but that one-handed method is difficult. Even if they understand it and try to do it, its not working very well and weve had injuries because of it, so were going to a new one.
This example illustrates that importance of clinician input once again. You cant underscore enough the need to get front-line workers involved in the evaluation of the device, because thats where the action is, McCormick continues. Sometimes when the rep comes and shows it to the manager, who doesnt use it very much, it looks good, but when you put it into use, issues may arise.
McCormick again emphasizes that healthcare workers must take responsibility for their actions. It is just very important for workers to realize that they have obligations in this as well, and one of them is to activate the devices, she says. To look into needle boxes and find unactivated equipment is really sad, because the facility spent a lot of money to buy that.
Given that the message about bloodborne pathogens has been repeated many times over the years, a fresh means of reinforcing its importance may be useful. Any time you can present local data, your own data within your own hospital, and you can identify according to the circumstances when the injury occurred, such as failure to activate, you can deem those preventable injuries, McCormick says. To provide people with data that says, In the last year, 28 percent of our injuries were deemed preventable because people didnt activate the device, youd better listen up on this one.
While national data, articles, and similar information is vital, first-hand examples are impossible to ignore. Nothing works better, although Im not advocating it, than a seroconversion, McCormick continues. Word travels fast. There have been articles written that described how, once there was a conversion, then administration got on board with the need for more emphasis and things were made available, etc. If that happens, very unfortunately, then use it for a teaching moment. Thats a possibility, but you really hope it never occurs.
McCormick also points out that in some instances, clinicians do something careless or out of the ordinary that leads to a needlestick, and thus may be hesitant to report it. There should never be a punishment because you failed to follow a technique, and that needs to be a very positive thing to make sure that it doesnt happen again, she says. You need to go over the details and see if it was a procedural issue or an equipment issue.
In addition to protecting themselves and their patients, healthcare workers who are conscientious about sharps safety also contribute to the protection of other facility employees. We occasionally still have a custodian who gets stuck because someone left a needle on the floor of the emergency room, McCormick says. We have an obligation to protect ourselves, be we also have an obligation to protect our fellow workers. You would never want to have that on your mind, that what you did possibly resulted in a seroconversion. Every person who uses a sharp is obligated to take care of it to final disposal. It doesnt matter if its the chief of surgery he or she has the same obligation. That needs to be reinforced by upper-level administration.
Clinicians are aided in their quest to create a safer environment by the increasingly large number of safety devices on the market. It always amazes me that when new issues come up in healthcare that manufacturers step up to the plate, says McCormick. For needlestick issues, companies are now becoming used to providing a place to stick that sharp tip until you can dispose of it where it belongs.
Theres so much new technology and more is coming out all of the time, Pugliese says. She also acknowledges that for improvement does exist in this sense nonetheless. There are a couple of areas in which there probably need to be more devices. More products for the operating room, probably, especially safety specialty blades. Surgeons seem to be resisting using safety blades, so there really needs to be an evaluation of whats out there and some additional safety blades perhaps. The other thing places where there might be some opportunities for creating more sharps safety devices would be introducer needles, spinal and epidural needles, arterial line needles, biopsy needles, things like that.
Occupational Exposure to Bloodborne Pathogens:
What HCWs Need to Know
In the 2003 publication Exposure to Blood: What Healthcare Personnel Need to Know, the Centers for Disease Control and Prevention (CDC) acknowledges that healthcare personnel are at risk for occupational exposure to bloodborne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Exposures occur through needlesticks or cuts from other sharp instruments contaminated with an infected patients blood or through contact of the eye, nose, mouth, or skin with a patients blood. Important factors that influence the overall risk for occupational exposures to bloodborne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection. Following a specific exposure, the risk of infection may vary with factors, including:
- The pathogen involved
- The type of exposure
- The amount of blood involved in the exposure
- The amount of virus in the patients blood at the time of exposure
Your employer should have in place a system for reporting exposures in order to quickly evaluate the risk of infection, inform you about treatments available to help prevent infection, monitor you for side effects of treatments, and determine if infection occurs. This may involve testing your blood and that of the source patient and offering appropriate post-exposure treatment.
How can occupational exposures be prevented?
Many needlesticks and other cuts can be prevented by using safer techniques (for example, not recapping needles by hand), disposing of used needles in appropriate sharps disposal containers, and using medical devices with safety features designed to prevent injuries. Using appropriate barriers such as gloves, eye and face protection, or gowns when contact with blood is expected can prevent many exposures to the eyes, nose, mouth, or skin.
What should I do if I am exposed to the blood of a patient?
1. Immediately following an exposure to blood:
- Wash needlesticks and cuts with soap and water
- Flush splashes to the nose, mouth, or skin with water
- Irrigate eyes with clean water, saline, or sterile irrigants
No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.
2. Report the exposure to the department (e.g., occupational health, infection control) responsible for managing exposures. Prompt reporting is essential because, in some cases, post-exposure treatment may be recommended and it should be started as soon as possible. Discuss the possible risks of acquiring HBV, HCV, and HIV and the need for post-exposure treatment with the provider managing your exposure. You should have already received hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection.
What is the risk of infection after an occupational exposure?
1. HBV Healthcare personnel who have received hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection.
For a susceptible person, the risk from a single needlestick or cut exposure to HBV-infected blood ranges from 6 percent to 30 percent and depends on the hepatitis B e antigen (HBeAg) status of the source individual.
Hepatitis B surface antigen (HBsAg)-positive individuals who are HBeAg positive have more virus in their blood and are more likely to transmit HBV than those who are HBeAg negative. While there is a risk for HBV infection from exposures of mucous membranes or nonintact skin, there is no known risk for HBV infection from exposure to intact skin.
2. HCV The average risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8 percent. The risk following a blood exposure to the eye, nose, or mouth is unknown, but is believed to be very small; however, HCV infection from blood splash to the eye has been reported. There also has been a report of HCV transmission that may have resulted from exposure to nonintact skin, but no known risk from exposure to intact skin.
3. HIV The average risk of HIV infection after a needlestick or cut exposure to HlV-infected blood is 0.3 percent (i.e., three-tenths of one percent, or about 1 in 300). Stated another way, 99.7 percent of needlestick/cut exposures do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1 percent (1 in 1,000). The risk after exposure of non-intact skin to HlV-infected blood is estimated to be less than 0.1 percent. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time).
What follow-up should be done after an exposure?
1. HBV Because post-exposure treatment is highly effective in preventing HBV infection, CDC does not recommend routine follow-up after treatment. However, any symptoms suggesting hepatitis (e.g., yellow eyes or skin, loss of appetite, nausea, vomiting, fever, stomach or joint pain, extreme tiredness) should be reported to your healthcare provider. If you receive hepatitis B vaccine, you should be tested 1-2 months after completing the vaccine series to determine if you have responded to the vaccine and are protected against HBV infection.
2. HCV You should be tested for HCV antibody and liver enzyme levels (alanine aminotransferase or ALT) as soon as possible after the exposure (baseline) and at four to six months after the exposure. To check for infection earlier, you can be tested for the virus (HCV RNA) four to six weeks after the exposure. Report any symptoms suggesting hepatitis to your healthcare provider.
3. HIV You should be tested for HIV antibody as soon as possible after exposure (baseline) and periodically for at least six months after the exposure (e.g., at six weeks, 12 weeks, and six months). If you take antiviral drugs for post-exposure treatment, you should be checked for drug toxicity by having a complete blood count and kidney and liver function tests just before starting treatment and two weeks after starting treatment.
You should report any sudden or severe flu-like illness that occurs during the follow-up period, especially if it involves fever, rash, muscle aches, tiredness, malaise, or swollen glands. Any of these may suggest HIV infection, drug reaction, or other medical conditions. You should contact the healthcare provider managing your exposure if you have any questions or problems during the follow-up period.