Sticking It to Us: Implementing Sharps-Injury Interventions
By Jenae Schlipman, BSN, RN, MBA/HA
The Needlestick Safety and Prevention Act (NSPA) was signed into law Nov. 6, 2000. This act guided the Occupational Safety and Health Administration (OSHA) to make revisions to its Bloodborne Pathogen Standard, published Jan. 18, 2001, taking effect April 18, 2001. A grace period was implemented to allow outreach and education to take place for both OSHA personnel and the public, so the act was not enforced until July 17, 2001.1
The requirement for healthcare facilities to adopt safety devices and engineering controls was not new to this legislation, since the requirement has been in effect since 1992. New requirements force healthcare facilities to document the input solicited from non-managerial staff in identifying, selecting, evaluating and implementing these safer devices, and to maintain a sharps injury log for recording exposures.
What are "Engineering Controls?"
The revised Bloodborne Pathogen Standard of 2001 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 needleless systems) that isolate or remove the bloodborne pathogen (BBP) hazard from the workplace."1
It is up to each employer to search the industry for these engineering controls, as OSHA does not provide a list of new safety products available or make recommendations regarding the usage of these safer products.
What if Alternatives are Not Available?
If a safety device is not available in the market to replace a specific device, we are not required to convert those nonsafety products to include safety features. We are, however, required to continually investigate new safety device alternatives at least annually for each device, documenting our ongoing efforts to convert any nonsafety sharps to include safety features.
Which Healthcare Facilities are Addressed?
Any facility falling under OSHA and having employees with occupational exposure to BBPs is required to comply with this federal law, regardless of the number of employees. There is a documentation exception for employers with 10 or fewer employees. These employers are not required to maintain a sharps injury log, and OSHA record-keeping requirements do not apply. However, they must still provide safety devices for their staff and adhere to the other OSHA Bloodborne Pathogen Standard requirements.2
One of the first things we did at The Children's Hospital (TCH) in Denver was to evaluate our BBP exposures from January to October 2001 to identify areas where frequent exposures occurred and identify specific devices involved in these exposures. Based on the exposure summary for this period, our high-priority devices included:
- Sharp instruments, including sutures, blades and knives
- Intravenous (IV) catheters
- Lack of personal protective equipment (PPE)
- Hypodermic needles
In a national sharps injury report, the Centers for Disease Control and Prevention (CDC) reported, "Up to 86 percent of needlestick injuries can be prevented by using safety-engineered needles and other devices." According to data collected from 55 hospitals by EPINet in 1997, the four most frequent sharps injuries involved the following types of blood-filled needles: butterfly needles, phlebotomy needles, syringes and IV catheter stylets. In addition, the injuries reported occurred 28 percent of the time during use and 22 percent of the time after use and before disposal.3
After identifying which devices to target first, we conducted researched to find the best safety device products available. Our hospital held an OSHA fair Dec. 3, 2001. Vendors offered hands-on demonstrations of safety products. This fair heightened awareness of new safety devices and provide information regarding the requirements of the NSPA for our staff.
Trials were conducted throughout the hospital and various clinics tested selected safety devices. Trials were placed in locations based on specific areas of expertise related to each product. Selected trials included participation of physicians and nurses, with nursing staff participating in all of the clinical trials. Participants were asked to complete written evaluations for documentation purposes, and not all safety devices and products were found to provide a safer option. Our decisions were determined by staff evaluations.
After adequate trials of each safety device, evaluations were summarized and decisions to implement various safety products were approved by our hospital's product evaluation committee (PEC) and OSHA council.
In-services were scheduled in January and February to provide staff with hands-on training. Staff members were encouraged to attend and sign-in sheets were kept for each department. The medical residents were trained at a conference in March.
After in-service training was completed, the materials management department made the appropriate changes for distribution of these products. OMNI cells and C-lockers were automatically switched out in both in-patient units and clinics, removing nonsafety items and replacing those items with the appropriate safety devices. In addition, a memo was sent to all TCH medical staff providing specific information surrounding the process of converting to these safety devices. This memo also was posted on the TCH Intranet.
The NSPA requires ongoing selection, evaluation, implementation and education of new safety devices as they become available. A safety device committee was formed, with representation from nearly every specialty to help evaluate new safety devices, and it reported monthly to the PEC.
Costs to convert to safety devices are steep. While additional costs related to conversion are incurred through products and training, there will hopefully be a decrease in the number of exposures and costs related to needlestick injuries.
The U.S. General Accounting Office (GAO) conducted an analysis of costs surrounding the implementation of safety devices.4 The analysis focused on healthcare workers (HCWs) in hospital settings, representing approximately 40 percent of HCWs nationally. The CDC estimates that 384,000 percutaneous injuries occur annually in hospitals. It is estimated that 69,000 needlesticks in hospitals can be prevented in one year by using needles with safety devices. This reduction may prevent at least 25 new cases of hepatitis B virus (HBV) infection and at least 16 new cases of hepatitis C virus (HCV) infection per year. An additional estimated 51,000 needlesticks could be prevented each year by using safer work practices such as:
- Creating appropriate locations for sharps containers
- Maintaining appropriate fill levels in sharps containers
- Not recapping needles
- Proper disposal of needles in sharps containers
Needles with engineered safety features are more expensive than conventional needles. The GAO projects that the annual cost increase in these expenses for hospitals will be between $70 million and $352 million. These estimates do not include costs such as training or time employees spend throughout the learning curve of introducing new products into their practice.4
We conducted a cost comparison of new safety products implemented at TCH. Data was gathered on safety device usage from a high-acuity inpatient unit at our facility. The data showed a cost increase of $1,150 to implement new safety devices in this unit.
The primary objective of the NSPA is reducing needlestick injuries. The aforementioned cost increases may be softened when applying the costs saved from fewer needlestick injuries per year. Published estimates of costs associated with needlestick injuries range from $500 to $3,000 per injury. Given that the reduction of needlesticks in hospitals is expected to be 69,000, hospitals will see a savings in post-exposure treatment costs of approximately $34.5 million to $207 million each year.4
The bottom line is that only those hospitals experiencing high-cost scenarios for post-exposure treatment will experience benefits exceeding costs when implementing safety-engineered devices. However, there is no price tag to show the savings for preventing just one staff member from experiencing the emotional stress of a needlestick injury, let alone the costs of a serologic test conversion.
BBP exposure rates are monitored very closely at TCH. Each month the following are tracked surrounding BBP exposures:
- Number of exposures reported
- Specific type of device involved in the exposure
- If a safety version of the device used was available
- How the exposure occurred
- If the injury was preventable
Implementation of these new safety devices was completed in February. We hope the number of BBP exposures will continue to decrease as staff use more safety products and gain familiarity with them.
Jenae Schlipman, BSN, RN, MBA/HA, has served as a pediatric oncology nurse for four years. She will begin a one-year administrative fellowship at Miami Children's Hospital this month.