The Role of Technology and Education in Promoting Sharps
By Kris Ellis
Infection control practitioners (ICPs) are intimately aware of the potential danger to healthcare workers (HCWs) posed by bloodborne pathogens via accidental needlestick injuries. While the exact prevalence of such injuries is unknown, the National Institute for Occupational Safety and Health (NIOSH) estimates put the number somewhere between 600,000 and 800,000 per year.1 Furthermore, about half of these are not reported. Other studies actively seeking to monitor the rate of needlestick injuries have reported as many as 839 injuries per 1,000 HCWs.2 The cost that facilities must absorb to manage these injuries is significant, and can become catastrophic if the injury results in the acquisition of an infectious disease.
It is widely recognized that the use of sharps safety devices and related products and technologies can be instrumental in helping facilities to protect their HCWs and patients. The Occupational Safety and Health Administration (OSHA) has enforced the use of sharps safety devices by employers since 1999, and recommends that front-line workers be involved in the selection and evaluation of safety devices.3 NIOSH recommends that employers of HCWs eliminate the use of needles where safe and effective alternatives are available, and implement the use of devices with safety features and evaluate their use to determine which are most effective and acceptable.
As technology continues to advance and an increasing number of classes and models of safety devices are made available, HCWs, and ICPs in particular, are faced with the continuing challenge of seeking out the best safety solutions, both in terms of cost and efficacy. Although potentially painstaking, this effort can have a significant impact on a facilitys overall level of safety and on quality of care. Continual education on and practice of proper techniques and device usage are also integral parts of any safety effort.
Regardless of what sharps system you have in your institution, you should continue to look (for a better alternative), says Providence Budet, RN, MPH, CIC, director of infection control at Bronxville, N.Y.- based Lawrence Hospital Center. No matter whats in place, I will always look to see if theres room for improvement, and of course there generally is, because the whole impetus of a sharps safety program should be to have a device that employs a one-handed technique that can be implemented without bringing your second hand into it so that you diminish the potential for a needlestick.
This attitude led Budet to initiate the implementation of retractable needle syringes at a large metropolitan facility in which she previously worked. After seeing the product showcased, Budet introduced it to the new products committee, where it was approved. The syringes were then brought in for trial.
Then, based on feedback from the nurses, because theyre the ones who use the needles most frequently, the determination was made to bring it into the institution, Budet continues. And of course part of that is based on the cost involved, and thats one thing that always makes it more difficult to bring in a new product the new product will usually be more than the previous one.
After some initial concern on the part of a few nurses about how patients would react to the new devices, a comfort level was soon established. Its like everything else everybody has a learning curve and everybody needs to have a chance to feel good about it, Budet says. This is a product that you can really feel comfortable with, because every time you depress that needle, it works. I cant begin to tell you how many shots Ive given, and I have not had one problem.
Youre not supposed to pull it out of the arm you just depress it and you make the needle fly into the barrel without removing it from the arm, so they thought the patients would be uncomfortable, Budet explains. Patients would ask, Is it out yet? and wed say, Its already over. Its in and out, and its so smooth.
In terms of impact on needlestick safety, the product switch was a resounding success. Its helped safety because, even if you wanted to recap, theres no needle there its gone, Budet points out. And people generally dont recap, so its not a problem because theres no needle there. So that walk from the site of use to the sharps container is a safe walk it is no longer a potential hazard or an accident waiting to happen.
As a longtime proponent of sharps safety, Connie Steed, RN, BSN, CIC, director of infection control at Greenville, S.C.-based Greenville Hospital System University Medical Center, has learned many valuable lessons in identifying and correcting safety issues. We have a pretty refined process, she says. We maintain data on all healthcare worker exposures in a database called EPINET, which was originated by Dr. Janine Jagger at the University of Virginia. We analyze that data on a regular basis and the data breaks down who gets exposed, how they get exposed, when they get exposed, and what they get exposed to. What you can do is analyze where your injuries are occurring and where you need to concentrate your focus.
We have safety devices, but there are some issues with why people pick the ones they use and do they activate them correctly, Steed continues. Those decisions as to what we focus on are based on data, and we analyze it, its reported out, its communicated back, and we base risk-reduction efforts on that data and we prioritize based on that data. Thats how our program is set up, and every year we develop objectives; targeted or focused objectives on what were going to focus on that year.
Steed explains that phlebotomy has been an area of concern in her facility for several years. We continue to have concerns about that area because those are high-risk exposures theyre hollow bore, so if I had my way we wouldnt have any, and thats not completely possible, but Im really concerned about those, she says. Analysis of the situation indicated to Steed that injuries were more prevalent with the use of certain devices. She also noted that established processes and procedures were not always being adhered to.
Part of the challenge in addressing the issue revolved around the number and variety of hospital employees who draw blood, according to Steed. A lot of hospitals have phlebotomists that draw blood all day long and thats all they do, but at our hospital, nurses and phlebotomists can draw blood, so we dont have as much control, she says. Instead of having 80 people who draw blood, we have 3,000. You can imagine if you have that many people doing the procedure it would be harder to control the process.
First, a team was put together to perform a root-cause analysis. Once the root cause of the exposures was identified, flowcharts were created for the procedures. What we found out was that some of it could be eliminated by using safety devices, but some of it was behaviors, like how the blood is transferred, Steed says. We identified opportunities in the process by flowcharting and then we looked for safety devices or changes in procedure that would eliminate the risk.
Several safety devices were implemented for each type of phlebotomy product that was being used, and education measures were improved. Steed notes that these efforts paid off in the end by decreasing needlesticks. We had to train folks and develop competency methods and measures because we have so many people who draw blood, and we implemented those things, and of course our exposures related to phlebotomy declined.
Pam Gill, RN, BSN, HIV prevention nurse at Statesville, N.C.-based Iredell Memorial Hospital, also advocates the proactive identification of devices that may be more suitable and safe. Recently, Gills facility made a change in their Huber needles based on front-line clinician initiative.
We already had a safety Huber needle in place, but our most experienced staff who used Huber needles came to us and they had seen a new one at a conference and were interested in trying it, says Gill. So we brought that in and did the training with a small group of people, which was our outpatient nursing center here. They wanted to try it, so we did a trial just in that department because they are the biggest users of that product.
Clinician feedback was collected, and patient reactions were taken into consideration as well. That was wonderful, because if youve got the nurses who say its a good product, and patients are also saying they like it, then we think we really have a winner, Gill says. Once we got the evaluations back, we knew we wanted to implement it in the other areas of the hospital that used Huber needles, so we used that department as our go-to people.
As other departments were trained, they were able to contact the clinicians who had originally evaluated and used the new products if they encountered any problems or questions. Thats great when you have access to another department whose staff kind of becomes your experts with a product, Gill notes. It also makes the rest of the staff more comfortable if their peers are saying they have used the product and like it, and heres how you do it safely. So that product was probably one of the easiest to bring in that Ive done in a long time, because it started with the users themselves wanting to implement it and evaluate it and then they were the contact people when we implemented it house-wide.
As dictated by the Occupational Safety and Health Administration (OSHA), the evaluation of new and innovative safety products is an ongoing effort in many facilities, even when needlestick exposure rates are low.
Diane Baranowsky, RN, nurse epidemiologist at Stamford, Conn.-based Stamford Hospital, is the chairperson of her facilitys multidisciplinary safety needle device task force, which seeks to address problem areas in terms of sharps injuries, and also constantly reviews new product information. Our goal is to be in compliance with the OSHA mandate, which is prevention of needlesticks to our healthcare workers, so one aspect of that is that we look at our pre-packaged kits or trays that are prepared by our various vendors and we solicit information from them as well.
Baranowsky explains that the task force continually searches for input and feedback from HCWs to help identify potentially helpful products. We solicit information both at a general orientation for our new healthcare workers, to see what they are accustomed to using and what they recommend, and then every month at the various in-service committees we solicit again what products are out there, and what people think we need, she says. Then well bring in a product, well evaluate it and make recommendations to trial it, and then trial it and purchase it based on the evaluations. Its a multidisciplinary effort.
The Centers for Disease Control and Prevention (CDC) supports the idea of a multidisciplinary leadership team when it comes to sharps injury prevention. The team should include representatives from many departments within the facility, including:
- Infection control
- Risk control
- Occupational health and safety
- Environmental services
- Central service
- Materials management
- Front-line clinical and lab staff4
Recently, this effort led Baranowskys facility to evaluate and purchase a needleless wound closure product. The product was evaluated and trialed by the physicians in our immediate care/walk-in area, so it was for the superficial skin injuries, she explains. It was trialed and purchased for that area, and it is presently being evaluated by our chief of OBGYN for use on the surgical patients in that area.
Although her facilitys existing wound closure product was also needleless, Baranowsky says the determination was made that there was still room for improvement. Wed had a liquid binder to replace suturing, so again our goal is needlestick prevention and were trying to be proactive, which includes being cognizant of the various products on the market.
The OR Neutral Zone
Although the implementation and correct usage of various classes of safety devices is a vital link in the chain of promoting sharps safety, education also plays a major role, and must be constantly evaluated and reinforced. An example is in the OR youve got to use a neutral zone, says Steed. Thats not a needle or device; its a zone where you set sharps. That takes major behavior modification, especially in our hospital system, where we have about 600 surgeons. In our OR experience, the neutral zone was the major emphasis, even though there were other things as well. We did implement some safety devices, but the biggest thing was the implementation of the neutral zone.
The scope of this effort was enormous, as Steed recalls. It was a major challenge and it took several years to get anywhere, because you had to continually repeat and repeat and repeat, but our surgical technician exposure rate has dropped tremendously, she says.
The need for education in this area was identified by careful analysis of exposure data. We focused on the surgical techs a couple years ago because they were our healthcare professional group that was exposed most; their exposure rate was tremendously higher than any other group, Steed continues. Their numbers werent higher, but their rate of exposure was higher.
After investigating the potential cause of these high rates, a course of action was decided upon. Quite frankly, they were getting stuck because of the surgeons, so we had to focus on behavior modification with the surgeons and technicians, and that led to tremendous improvement, Steed says. We found that the best way to get the surgeons is to set up tables, so we set up a table right by the door where they go in to change into scrubs. We put a table there and we put different things that could serve as a neutral zone on it we wanted their input on what they could use, and at the same time we were educating them about the need for the neutral zone.
Resistance to change can be a significant hindrance in a large initiative such as this, and Steed contends that hard numbers are a necessity in communicating the need for new procedures. We showed them the data we showed them that they were sticking people and that in order to keep that from happening, a neutral zone needed to be used, she says. Thats how the education occurred, but what we found is that it had to be done consistently and in an ongoing fashion over about a year. At the same time, we had the OR nurse managers monitoring the use of the neutral zone, and when they didnt see the use of the neutral zone, they said something about it. They still do that today. That monitoring by the management staff is one of the most important things that has helped.
Staying abreast of changes in technology and behavior and evaluating them relative to a facilitys own unique circumstances must involve data, according to Steed. Weve been very successful here, she continues. New things and new trends come up, and thats why you have to have data. You cant say, Ive got my safety device, so I dont have to worry about it anymore, because things can happen. So you have to monitor your data, and if a problem occurs, your data helps you to figure out whats going on so that you can focus on it.
Needleless IV Access
The journey toward needleless IV delivery systems was significant in terms of reducing exposures at Gills facility. When we quit using needles in our IV lines, our stick rate just dropped drastically; it made such a big difference in the sticks we were getting at the bedside accessing IV lines, she says.
Gill explains that she and her colleagues began constructing their own set-ups long before fully needleless IV systems were introduced. We started piecing together ports where you could access it with a syringe and not have to put a needle in a port, so thats how long ago we started to put it together, she recalls. We just got things in bits and pieces and tried to make it as safe as possible, and we would put these caps on the ends of our IV lines and the Y-ports in our IV set-ups so that we wouldnt have to stick a needle in them.
As new and better technologies in this area were evaluated and purchased, safety rates improved even more. However, Gill is quick to point out that acquiring the best devices is only part of the equation. Its a whole process, she says. You cant just throw products out there and say use these theyre safe, I just dont believe in that. You have to stay with your practice and education, because you can still get stuck with safety products.
To Gill, effective education means making sure that every clinician who will be using a new device is competent and comfortable with it. The follow-up is important for those who never quite got the technique down, who maybe needed just a little more time with the product in their hands, she says. When youre trying to prevent sticks, you dont want even one, so that person who got left behind in technique, thats the reason you follow up continually, and you have to watch them and pick them out.
Gill goes on to describe an example in which she was evaluating nurse competency with a certain device. One nurse in particular seemed to be having some trouble mastering the technique. I watched her do it, and it was very awkward what she was doing, and I could see that she was easily going to be stuck, so I said to her, Let me show you how to do this then I want you to do it again, Gill relates. After taking the time to work with the nurse and communicate about the technique, Gill discovered that the nurse was left-handed and was attempting to use her right hand as the dominant hand since she was told to perform the technique exactly as the person who taught her had done. So it could be something as simple as that, Gill explains. If you can uncover things like that, it demonstrates the importance of the follow-up and being there for them and watching them do it again and again.
1. NIOSH Alert: preventing needlestick injuries in healthcare settings. DHHS (NIOSH) Publication 2000-108.
2. Lee, JM, et al. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN J. 2005 Mar;53(3):117-33. Review.
3. Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; final rule. Occupational Safety and Health Administration (OSHA), Department of Labor. Fed Regist. 2001 Jan 18;66(12):5318-25.
4. CDC. Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program, p. 1.