Infection Control Today - 05/2004: In the Name of Safety

In the Name of Safety
Building a Bloddborne Pathogens Program

By John Roark

Education, vigilance and a culture of safety help create a secure environment for healthcare workers and patients.

There are two classes of blood and body fluid exposures: mucocutaneous (exposure of the eyes, nose, or mouth as a result of splashes, spray, or direct contact) and percutaneous (needlestick and sharp object injuries to the skin). Mucocutaneous and percutaneous exposures have different pathogen transmission rates and require different prevention methods. Of the two, percutaneous exposures are the most common occupational injury as well as the most common type of bloodborne pathogen exposure among healthcare workers.1

Occupational exposure to bloodborne pathogens from needlestick injuries and other sharps injuries is a serious problem but is often preventable, says the Centers for Disease Control and Prevention (CDC), which estimates that each year 385,000 needlesticks and other sharpsrelated injuries are sustained by hospital-based healthcare personnel.2

Although standard precautions were introduced in the 1990s, research continues to report less than 100 percent compliance among healthcare professionals with measures demonstrated to decrease disease transmission.

In my opinion, the biggest challenge is in the reporting and follow-up of the exposed healthcare worker whether by needlestick injury or mucous membrane or non-intact skin exposure, says Elizabeth F. Chinnes, RN, BSN, CIC, infection control consultant, IC Solutions. In many facilities in which I have worked or consulted, large and small, there is not a good system to handle reporting and follow-up of bloodborne exposures. Often times, the employee is to report to employee health office during normal business hours and another site during evenings, nights, and holidays. The process is often hindered by the employee sitting for hours in the ER its not considered a true emergency when in fact, it is or even being sent off site for follow-up.

In addition, the more complex our procedures are, the more difficult reporting is to enforce. There are many areas for the incident to slip between the cracks in the modern healthcare system. For example, some facilities, and even physicians, do not order the appropriate bloodwork on the source from whom the employee was stuck and/or on the employee. This in turn delays our actions and causes us to have to retest the blood sample for the appropriate tests for bloodborne pathogens.

Old Dogs, New Tricks

Nurses are trained well in nursing school, says Terry Jo Gile, MT, (ASCP) MA Ed, president of Gile and Associates, a consulting firm that specializes in keeping work environments accident-free. They enter the field and another nurse who has been there for 30 years says, Let me show you a shortcut. Its always worked, Ive never stuck myself. All of the wonderful training that theyve received goes down the tubes. Thats one of the challenges the more experienced employees using time-honored shortcuts that circumvent the safety issue.

Deeply ingrained behavioral patterns are an obstacle, and although change is constant, getting healthcare workers to change their habits and think safety-smart doesnt happen overnight. It is important to note that the Occupational Safety and Health Administration (OSHA) can hold a facility accountable and can issue citations and fines if safety practices are not followed.

I think that behavioral change is a big challenge, says Keith Kaye, MD, MPH, associate professor of infectious diseases at Duke University.

Healthcare workers are often resistant to changes and new devices, but if you can teach them how to use new devices, they will eventually accept them. Often you have to switch out old products; you have to be aggressive about it if you keep the old product, people will still use it.

What Works?

An effective bloodborne pathogens prevention program includes several fundamental components that must work in concert to protect healthcare workers from exposure. Policies and procedures that promote a culture of safety have a trickle-down effect on acceptance and adherence to engineering controls, safe work practices and personal protective equipment (PPE).

In healthcare, there has traditionally been a hierarchy in terms of a from-the-top-down approach, says Michael Tapper, MD, an epidemiologist at Lenox Hill Hospital, New York, and past president of the Society for Healthcare Epidemiology of America, Inc. (SHEA). Healthcare, for many people in lower socioeconomic levels, is entry level to the workforce. If you look at the people who are at the lowest levels of healthcare many of them are non-American born. For many of them, this is the beginning of the American dream. At the same time, theyre often less well-educated than U.S.-trained people, theyre less well educated than the average trained physician or nurse, theyre more easily intimidated, less likely to demand certain levels of protection. Or theyre more likely, if that protection is not there, to be intimidated into doing their job anyway.

Organizations with strong safety cultures consistently report fewer injuries than organizations with weak safety cultures. This happens not only because the workplace has well-developed and effective safety programs, but also because management, through these programs, sends cues to employees about the organizations commitment to safety.4 Workers are more likely to report if a well established and known plan is in place. This requires constant education and reminders such as posters throughout the facility, updates in orientation for new staff and yearly reviews and newsletters.

Simplify your process, delete unnecessary steps, says Chinnes. If possible, have packets put together which lead the healthcare worker or supervisor in a step-by-step fashion through the steps to follow if they receive a bloodborne exposure even to the point of lab slips which are filled out for bloodwork on the source and the employee. Ensure that new safety devices are inserviced on all shifts and in all departments where they will be used. Dont forget that education is not a one-step process. Particularly if there is a problem with a new device, the staff may need more education and reinforcement periodically. We each need to assume personal responsibility to make our workplaces safer and even look at near misses to determine what we could have done differently.

Defense, Not Offense

The first line of defense is a prepared healthcare worker who understands the risks and takes the proper precautions, says Tapper. In the hierarchy for sharps injury prevention, the top priority is to eliminate or reduce the use of sharps where possible. Next is to isolate the hazard, thereby protecting an otherwise exposed sharp, through the use of an engineering control such as self-sheathing needles and needleless devices. When these strategies are not available or will not provide total protection, the focus shifts to work practice controls and personal protective equipment (PPE).

Engineering Controls

Engineering controls eliminate or isolate a hazard in the workplace. The emphasis on engineering controls has lead to the development of many devices with injury prevention features. Safety devices on needles have greatly reduced needlestick injuries.

The most important safety devices that have come out are the safeties that go over the needles that we are using on a routine basis, says Peggy Gutman, RN, BSN, COHN-S, director, occupational health services, Childrens Memorial Hospital, Chicago. The changes in the safety devices over the last three years have been dramatic. Theres practically no sharp instrument out there that you dont have an option to buy with a safety device on it. Those are really helping to reduce some of the injuries.

But, Gutman points out; all the safety devices in the world can not eliminate accidental exposures that are going to occur.

I find that my biggest challenge is accidental injuries, particularly those that occur in situations where you have very limited time theyre not thinking about safety, theyre focusing on an emergency, she says.

Tapper agrees. Everyone will tell you that they practice great infection control, but when the ER is jammed with people, things seem to get more difficult. When the ICU and nursing unit are well-staffed, things go relatively well. As soon as things get hectic, as soon as people get busy, as soon as theres a bigger patient volume than you can easily demand, things get a little sloppy at all levels of infection control. And I think thats generally true in terms of bloodborne pathogen protection as well.

When people are stressed, when people get busy, thats when accidents are going to happen. The other problem this creates for post-exposure is that it delays the time that the individual actually reports the incident, says Gutman. In a high-risk situation, theyre going to take care of the trauma first and report the injury later, which means that that inoculation is in their system for a longer period of time before you have any kind of opportunity to do any preventive treatment. If we do need to give prophylactic medications, ideally, we attempt to do that within 24 hours.

No single safety device or strategy will serve as a panacea, or have the same efficacy in every facility. Employers must develop their own programs to select the most appropriate instruments for their specific settings.

The key to successful prevention, says Peg Luebbert, MS, MT (ASCP), CIC, system consultant for infection control, Alegent Health, is a user-friendly sharp in the hands of an educated user. If youve got the right sharp and youve educated the staff on how to use it, theyll use it. You can have a lousy sharp and you can educate and educate. But if that sharp is not user friendly, theyre not going to use it, and vice versa. You can have the best sharp in the world, but if they dont know how to use it, they wont.

One hindrance to the widespread use of some safety devices is cost. Spring-loaded syringes which automatically retract the needle into the barrel of the syringe may have a greater degree of safety than triggered devices, but are cost-prohibitive.

It all comes back to cost, says Tapper. Yes, you can engineer a better safety syringe. Yes, you can engineer all kinds of devices. But many of these safer devices are considerably more expensive. The industry continues to move toward safety, but safety still comes at a very high price when theres very little fat left to squeeze it from someplace else.

We also have to be careful as we introduce safety devices to make sure that the purpose which is to not only protect the worker, but to protect the patient is being looked at, he continues. In the rush to get them on the market, some safety devices of have not been as carefully studied, and some of them may have down sides in terms of patient care.

Safe Work Practice Controls

Work practice controls changing the way in which a task is performed is an important component to preventing bloodborne pathogen exposures. Due to the high frequency of blood contact and percutaneous injuries, body substance exposures are even greater among personnel working in the OR. Surgery requires the use of sharp instruments, sutures with needles, and speed, which add up to a hazardous work environment. Reducing the risk of sharps injuries, particularly in the OR, can be facilitated by implementing safer practices, such as announcing that a scalpel or other sharp instrument will be passed, the use of a neutral zone in which sharps may be placed and retrieved (to reduce hand-to-hand transfer) and never tying sutures with the needle in hand.

Having an effective disposal system in place for used sharps is an important work practice control. Sharps disposal boxes should accommodate varying sizes of needles, should be conveniently located and readily accessible.

If disposal boxes are on the nurses medication cart, but that cart is way down the hall, chances are someone is not going to run down the hall to dispose of a sharp. Theyve got to be available at every point of use, says Tapper. Youve got to make sure of subtle things that sharps disposal boxes are mounted at eye level, where everybody can see whats inside. If youre standing up looking down into the sharps disposal box, youre not likely to stick yourself because you can see the contents.

But if youre a nurse whos five feet tall and the box is conveniently mounted so that taller people can see down into it, you have to reach up with your hand. Imagine putting your hand into the basket and you really cant see where your hand is going. You could drop something in and get stuck with a needle. If there are 60 empty syringes with needles, whose needle was it? Did it come from a patient with HIV, or was it a clean needle that was dropped in there?

One of the things that worked very well for us was to do a walkaround inventory of where our safety disposal devices were, how they were mounted, what wasnt mounted and secured, how many feet were people having to walk from the point of use to disposal says Gutman. A lot of our needlesticks were happening at the point of disposal. A good sharps container program and ideal mounting location is really important. OSHA does provide guidelines, but I think many times they are overlooked because there are so many things that go into a patient room so many things on the wall. The containers have also been greatly improved thanks to the manufacturers, and its very difficult to access a box and get hurt.

Again, Tapper references the hospital pecking order. Youve got to make sure someone empties [the disposal box]. Remember that hospitals are hierarchical. The people who usually get laid off first are the housekeeping people the lowest people on the totem pole, sometimes not entirely protected by union contract. If they go, then who empties it?

Personal Protective Equipment

The final line of defense is personal protective equipment. This level is meant to supplement engineering and work practice controls if the first two controls cannot eliminate a problem, the third can mitigate its effects. In the OR, gloves, gowns, masks, and protective eye wear are examples of this third level of control.

You have to evaluate every task that you perform that involves blood and body fluids to determine what kind of exposure youre going to have, says Gile. Can an engineering control be put into place so that the stick/splash/spray can be completely avoided?

Surgical masks and goggles are the two of the most commonly used pieces of personal protective equipment. Masks are worn for surgical asepsis and to prevent contamination of the mucous membranes of the nose and mouth of the person wearing the mask. The use of face shields is less common.

While not as prevalent as percutaneous exposure, mucocutaneous exposures are nonetheless of significance, and PPE is a sentinel means of defense. Protecting the eyes, nose and mouth from direct contact with possibly contaminated body fluids presupposes the use of masks and shields readily available and consistently employed.

Nobody wants to get splashed with blood thats Hep B- or C-positive in their eyes or in their mouth, says Tapper. Weve had some engineering controls to deal with that. Thats one of the things that you try to do you look at procedures and ask, is there a safer way to do this? Do I have to do it just because its always been done this way?

Until recently, gloves have been worn primarily to maintain sterility of the surgical wound. Glove use for protection of OR personnel is an extension of that practice. Standard precautions require that gloves be worn whenever there may be contact with blood and body fluids, when touching mucous membranes and nonintact skin, when handling contaminated instruments, and when performing venipuncture or other vascular and arterial access procedures. Unfortunately, faulty surgical gloves have been all too common, although it is believed that the quality of gloves is improving.5

Using PPE is where we sometimes see a lot of downfall, especially eye protection, says Gutman. I think that eye protection is just not a natural thing. Weve gotten used to using gloves in healthcare. Even before bloodborne pathogens, gloves were there and we used them for some things. After bloodborne pathogens became a very significant concern, there was a lot of gloving. But no one expects or plans for a splash. They overlook the fact that they might need that protection when they go in to start a procedure, or do something where they could potentially be exposed to a splash. Thats a real challenge. Its an opportunity for us to provide creative education.

Gloves, gowns, shoe covers, and caps have been worn to maintain asepsis. Safety recommendations for the use of these items have been aimed at preventing blood or body fluids from contact with health care workers skin and underclothing. Gowns vary in their ability to resist liquid penetration.4

It is important to note that although PPE provides a barrier to shield skin and mucous membranes from contact with potentially infectious body fluids, most protective equipment can easily be penetrated by needles.

A Changing Culture

Healthcare workers are increasingly demanding that they should have the same level of protection that other people have, and that just because youre a healthcare worker doesnt mean that youre willing to undergo risks to your own health, says Tapper. The consequence is not just for you, but for your spouse, your kids. The culture is changing, Im not sure that across the board the quality of the services is really there to the same extent that we would hope it would be at this point. A lot of thats driven by finances. I think that these are all things that people would do if the money were there.

Luebbert sees practicing safety as a means of far-reaching impact for healthcare workers. The role of infection control and safety is not so much to do infection control, but to be there in their face, to be their conscience. To reinforce, I need to take care of myself. I need to protect myself. I need to worry about taking things home to my family as much as I am protecting the patient.

Looking ahead, Gutman believes that teamwork can have a significant impact on effective bloodborne pathogen safety.

Are we ready now to start saying lets do something as a group to focus our energy on looking at each other and how were doing these things? Before you can do that you have to create a culture of collaborative approach to solving problems. I think that people from the outside look at us as a healthcare team more than we start out that way internally. Weve made a very concentrated effort for a number of years on culture change. As the concept of teamwork becomes integrated and becomes the way of doing all things, I think the opportunity is there in terms of sharp safety to use that same concept of peer review and collaborative approach to solving the problem. We should be able to go back and say, Look, youre falling out of range with other areas inhouse, heres what seems to be happening and these are the statistics, what do you think the problems are? Give them the opportunity to take charge and take control. If they can be responsible for problem solving within their own areas, then well work around some of these emergent actions that are now the roadblock.

I really think thats where our future is. Weve gotten about as far as we can with adding the safety devices. The manufacturers will tweak and improve things a little bit, but most of the products have now been touched on and the redesign is there. Affordability will get better and better. I think now were on to that more difficult approach: just how do you get people to do the right thing all the time? Thats the future.

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