New Developments in Primary Prevention and Sharps Safety
By Steve Bierman, MD, and Brad Poulos
While preventable medical-sharps injuries still occur at a disturbing rate, healthcare workers can feel heartened by some positive events over the last several months. In particular, two vulnerable groups nurses and physicians-in-training are better protected today because of recent developments in the regulatory area.
These developments include a new fact sheet on catheter securement from the Occupational Safety and Health Administration (OSHA), as well as major new enforcement actions by OSHA against hospitals that violate its Bloodborne Pathogens Standard (BPS). The nonprofit National Alliance for Primary Prevention of Sharps Injuries (NAPPSI) has played an active role in disseminating information about these and other developments that affect infection control professionals.
With an estimated 590,000-plus clinicians and other healthcare workers (HCWs) victimized by accidental needlesticks every year, sharps safety continues to be an essential focus. OSHA plays the most prominent role in this area, either through the federal administration or through individual state OSHAs. These agencies can fine hospitals and publicize their actions, either in response to anonymous HCW complaints about unsafe devices or, in many cases, as a result of unannounced inspections of workplaces such as hospitals.
Most recently, OSHA issued a new fact sheet in February 2004 that clearly delineates the needlestick risk posed by catheter placement. The fact sheet describes the potential advantages of using adhesive anchors, instead of tape or suture, to secure catheters. This technology greatly reduces or even eliminates needlestick risk related to catheter securement.
The OSHA fact sheet, titled Securing Medical Catheters, noted that all catheters for vascular access must be inserted with a needle. Therefore, inserting a catheter exposes the healthcare worker to the risk of a needlestick. This is the first time OSHA had so directly connected catheter placement and sharps injury risk. The fact sheet also stated that adhesive anchors are a suitable alternative to tape or suture, the traditional methods for securing catheters. In the case of suture securement, OSHA pointed out that adhesive anchors eliminate the direct injury risk posed by suture needles.
The fact sheet also stated that adhesive anchors can provide improved catheter stability, thereby decreasing catheter migration, dislodgment, and the necessity of reinsertion with its associated needlestick risk. In other words, adhesive anchors can do a better job of securing than either tape or suture, greatly reducing a second level of sharps injury risk: the needle exposures from unplanned catheter restarts. This, too, is new territory for OSHA, which had not previously recognized the needlestick danger from tape securement.
OSHA also played a central role in a major violation citation against a prominent New York City teaching hospital. In September 2003, OSHA fined Montefiore Medical Center $9,000 for multiple violations of the BPS. The violations included 26 instances of failure to use safety-engineered devices. The case was initiated by a complaint filed by Montefiore medical residents. Its worth noting that the hospital, which has contested OSHAs action, was not wholly or flagrantly noncompliant with the BPS. Rather, the hospital was fined because its needlestick-safety efforts were insufficient, not because they were wholly lacking.
Steve Cha, MD, chief resident in internal medicine at Montefiore, was the lead complainant against Montefiore. He told Advances in Exposure Prevention, a publication of the International Healthcare Worker Safety Center (University of Virginia): In terms of implementing safety, Montefiore has certainly made progress. [MMC] is probably pretty typical of many large teaching hospitals in that respect; its done a fairly good job with safety. But I think the message here is that pretty good is not good enough.
Primary prevention perceived a significant boost from OSHAs action at Montefiore and the attention this action has received. Among the customary practices for which Montefiore was cited was the practice of suturing (and the attendant exposure to dangerous suture needles), when sutureless alternatives such as adhesive anchors are available, appropriate and feasible.
The message is also that hospitals dirty laundry may not be kept inhouse, if airing it helps protect healthcare workers. Cha joined Sidney Wolfe, MD, director of Public Citizens Health Research Group; Lauren Oshman, MD, MPH, president of the American Medical Students Association, and others in signing a bluntly worded letter about Montefiore to the president of the American Hospital Association (AHA). The letter started off by requesting that the AHA alert members to OSHAs sanctions against Montefiore. The signers noted that conditions similar to those at Montefiore likely existed at other AHA institutions, putting physicians-intraining, nurses, and other hospital staff at risk and exposing the institutions to OSHA sanctions of their own.
But the real thrust of the letter came at the end: If hospitals failed to adopt available safe devices, medical students and residents stand ready to file institution-by-institution complaints against violating hospitals. This position has strong support from NAPPSI.
To make sure their concerns were well-understood, Cha and Public Citizen also published the letter he received from OSHA detailing the complaints against Montefiore and OSHAs response. The documents are available at www.citizen.org/publications/release.cfm?ID=7287.
OSHAs actions in the Montefiore case suggest that the agency will no longer be content with partial efforts to comply with the BPS. Clearly, institutions will be targeted for action even if they have implemented some safety devices, as long as they continue to use traditional devices in other areas where newer, safer alternatives are available.
Thats not the only red alert on the OSHA front. Two months prior to the Montefiore citation, OSHA slapped a Beaver Falls, Penn. nursing home and its parent company with $92,500 in fines for BPS violations. The fines included $70,000, OSHAs maximum, for a willful failure to use safety devices. The maximum penalty was unprecedented for a safety devices violation, another sign that OSHA is losing patience with institutions that ignore the BPS.
More Sharps-Safety News
Since last fall, several other developments have also helped spread awareness about more effective sharps-safety approaches. These developments include:
- A campaign to protect physicians-in-training from suture needlesticks. NAPPSI advocates a sharps-safety strategy called primary prevention. Primary prevention employs an obvious logic: eliminate the needle and eliminate the risk. Practices and technologies that eliminate medical sharps should be used, wherever feasible to maximize healthcare workers safety. This approach is superior to secondary prevention technologies that render sharps safer. Secondary prevention technologies sometimes fail, and can also be improperly deployed by negligent or poorly trained workers. NAPPSI also supports secondary prevention when primary prevention is not appropriate. Among NAPPSIs membership are various professional nonprofit associations, more than 20 medical device manufacturers, and more than 4,000 individual clinicians.
- Last year, NAPPSI launched a campaign to protect medical interns and residents from accidental suture needlesticks. Protecting Americas Interns and Residents from Sutureneedle Sticks (PAIRSS) is aimed at teaching hospitals. For training purposes, physiciansin- training are often asked to perform unnecessarily risky procedures such as suturing catheters, when sutureless alternatives are available. By raising awareness of primary prevention, NAPPSI hopes to reduce the high rate of injuries that occur in teaching institutions. As part of the PAIRSS campaign, NAPPSI sent a letter to the president of the American Hospital Association expressing support for the position of Montefiore Medical Centers residents. The letter also requested that AHA members be urged to adopt specific devices and techniques that prevent suture injuries. In addition, NAPPSI sent a letter to OSHA assistant secretary John Henshaw commending the agencys action in the Montefiore case and explaining the primary prevention strategy. NAPPSIs sharps-safety campaign for medical residents has been covered by a number of media outlets, including American Medical News, a publication of the American Medical Association.
- The Association of Occupational Health Professionals in Healthcare (AOHP), a NAPPSI member, formed an alliance with OSHA in February 2004 to protect employees health and safety. Among its primary concerns, the alliance tries to reduce HCWs exposure to hazards associated with patient handling and bloodborne diseases.The alliance also focuses on the implementation of best practices and technologies at healthcare facilities. As part of the alliances efforts to promote safer working conditions in the healthcare industry, it is training each organizations professionals in jointly determined best practices and effective approaches.
- Earlier this year, NAPPSI and AHOP published results of a preliminary but significant survey on sharps injury risk to medical students, interns, residents, and fellows. The results were described in an article by AOHP president emeritus MaryAnn Gruden, CRNP, MSN, NP-C, COHN-S/CM, and NAPPSI president Steve Bierman, MD, in the February 2004 issue of AOHP Journal. One notable result of the survey concerned curved suture needles.
The survey showed that manual manipulation of suture needles caused a much larger proportion of reported injuries (33 percent) than any other root cause. That in itself was not surprising. A published analysis of 2,111 percutaneous injuries in a teaching hospital had found that a similar percentage (35 percent) of injuries to interns and residents were caused by suture needles. However, the new survey also found that the overwhelming number (91 percent) of suture needlesticks was caused by curved suture needles, which many physicians mistakenly believe to be effective safety devices. The survey results further underlined the wisdom of primary prevention. Accidents can still occur with safer sharps such as curved suture needles. Clinicians would be much better protected if they were provided sutureless technologies and were trained in their use. Among other important statements, the authors also noted that hospitals group purchasing contracts for bulk discounts are problematical, if their supplier doesnt stock sharps-safety devices. The authors recommended that such institutions develop more flexible purchasing arrangements to protect their workers, if certain appropriate safety devices are not available on contract.
Safer Days Ahead?
Although the solutions to the sharps safety problem seem frustratingly obvious to those of us who work closely with the issue, getting institutions and personnel to adopt new habits and technologies is always an uphill climb. But the pace of change can really speed up once a threshold is reached. The Montefiore situation and the issuance of the OSHA fact sheet are major developments, and the other events just discussed add to the momentum. Widespread sharps safety may be reaching a tipping point, where the adoption and standard use of the best safety devices truly becomes standard operating procedure, as required by law.
Steve Bierman, MD, is president of NAPPSI and Brad Poulos is NAPPSIs executive director. NAPPSI membership is free to individual clinicians and non-profit organizations. Visit www.nappsi.org or call (858) 350-8623.