Smart Sharps Evaluation
Making a Case for Change
By Kathy Dix
Introducing a new sharps-safety device to your facility takes more than just purchasing the product and making it available; you must often create a committee to review possible replacements for primary and secondary sharps injury prevention devices. The committee must narrow the field of options, test the devices in various departments in the facility, get feedback from end users, purchase the item, inservice employees on its proper use, and then convince them to use it.
One of the first steps is cost analysis, says Terry F. Davis, RN, MSN, nursing director at Brownsville Community Health Center in Brownsville, Texas. We were using a BD regular syringe, and with that cost analysis, of course, you have to include costs for personnel and equipment that you use. Some of the variables are the same alcohol swabs and your two-by-twos but red trash, we calculate by weight because we pay by weight. We assessed the number of containers we were going through in a period of a week, and how many needles and syringes we went through, how many red boxes we went through, how much that was going to cost to process by the maintenance crew, the frequency of having them change the boxes and empty the red trash, she says.
Then we compared that against the SafetyGlide. I do use that as well. But very few people use them; mostly its for LVNs and RNs, because were mixing medications. I chose to go with the Biojector. We thought it was going to be astronomically unattainable in a community health setting, because were nonprofit. We had seen it, I think back in 1997, at a national immunization conference. We were quite taken with it, but it didnt look attainable at all very expensive. I did a cost analysis just the same; our immunization nurse kept saying for two or three years, I wish we could get Biojectors, Davis recalls.
After we were mandated to go with a safety device, we did the cost analysis on it, and it was because of the large volume that we do. We give more than 20,000 to 22,000 immunizations per year. When I did the cost analysis, there was no red trash, and there was a big chunk off it right there. That helped ease the pain of the cost of the Biojectors. Kurt Lynam [at Bioject] was so good to work with, he was so helpful and not pushy like a salesperson normally would be. I asked a million questions, and he sent one of his nurses down here to demonstrate this to us, and he gave three of them to us for a two- or three-week trial. We used them with vaccines, because you can only use up to 1 cc at a time, but what we give primarily here is vaccine (flu shots and pneumovax), so it works well for us.
Davis facility has many medical assistants giving shots who are not licensed nurses and therefore must be trained, retrained and made proficient in using needles. During that cost analysis, I calculated how much it cost us for two needlesticks that year. With the costs of the red trash and the needlesticks and we process needlesticks in-house, so its less cost than if we had sent them to the hospital and the volume of shots we were going to give, it actually turned out to be a little less expensive to use the Biojectors and it was totally safe. We have not had a needlestick since; in the nursing department, we have totally eliminated the needlesticks for about four years, she reports.
Weve had a lot of training, because you have to perfect your technique so you do the most painless shot. It does pierce the skin and has some discomfort to it. Here, we give up to about eight shots to one child on the same day, so youre using all the arms and legs. We give [the shots] according to least painful first, the most painful last. When we had the trial with the Biojector, [the children] were in for their shot and then would come back for a booster and we didnt have the Biojector anymore. Theyd say, I dont want the needle; I want the Biojector. Wed say, Were thinking of buying them, but we dont have them yet. The kid would say, Ill come back for my shot when you get the Biojector.
A small percentage of people do not like the Biojector, Davis relates. That would probably be a person who had a bruise. That has happened to one of our own MAs when we were trying it out on each other, but I believe that was lack of perfection in the method, she says. I had the Biojector training nurse come down from Oklahoma; shes been here on three different occasions. The last time I brought her because we had a fairly big turnover in staff, and I thought it would be best that she give everyone a thorough going-over. I used to have a little trouble with one medical assistant in particular; she really didnt want to use the Biojector. She was finally told, You are not going to have needles, so she had to use the Biojector. Every 18,000 shots, you have to send the Biojector in for an overhaul. I told her, Its going to have to go in for repair, and she practically hugged it, and asked, How long is it going to take to come back? They promised one to replace it while it was being fixed, so she was OK with that.
Other facilities have also had success with the Biojector; one of these is Gila River Healthcare Corp. in Sacaton, Ariz., which provides quality healthcare to the Gila River and Ak Chin Indian Communities. We dont call it a gun; we say its like the tasers on Star Trek. They love that, says program manager Cathy Denny, RN, MSN, FNP-C. Weve kept a couple demonstration syringes, to prove to the older kids in middle school and high school that theres no needle, because theyre not quite sure they believe us.
When the program first started nearly seven years ago, the immunization compliance rate for schools in the Gila River Indian Community was approximately 20 percent. We were looking at ways to improve that. Because its a reservation, theres a lot of poverty here, and transportation is a huge issue, so we decided to hold school-based clinics, Denny recalls. One of my staff happened to see an article about needle-free systems and the Biojector, so we checked it out and decided that was the way to go for several reasons. It promised to be a faster method when were looking at upgrading 3,000 kids on their immunization status, we gave a lot of shots and just the safety issue, not only for the kids but for us.
She continues, Wed go to the schools and have immunization parties, and at one, we had clowns and popcorn machines and balloons. We not only did the school kids, but if the parents wanted to bring younger kids there, wed do them, too. We were giving sometimes five and six shots I use the term loosely and nobody would have to hold down the kid. You didnt have this child thrashing around.
The risk of getting stuck with a contaminated needle was extremely high using needles, even the safety needles, because perhaps the child moves, bumps your arm, and you end up giving the shot to the person next to her. Wed be at a school doing a clinic, and even though it was not time for their shots, some kids would come up and say Arent you going to give me one? I want a shot, too. How many kids have you seen ask for a shot?
Over at our outpatient clinic at the hospital, frequently wed have kids that wed given vaccines with the needle-free system at school whose parents would bring them into the clinic. The employees would try to give them their shot with a needle, and theyd scream, I want the gun, even though we never called it a gun. Wed have to go over there to give it to them with the needle-free system, she adds.
It really was a tremendous success with the kids. If you look at the syringes themselves, theyre a little bit more expensive than the standard syringe and safety needle system, but when you add in the fact that you dont have to utilize sharps disposal, because theres no needle that can go in the regular garbage, that cuts costs. We figure that if you had one positive needlestick, that would pay for years of syringes, Denny points out.
To evaluate the product, she and another nurse practitioner tried the Biojector with saline on each other. Because they hadnt been trained in its use, however, it hurt a great deal. We were doing it wrong, she explains. We were about ready to send it back, but then they trained us. We had a trainer come out on the first day, and then we had a clinic scheduled the next day. She went out with us and did handson training with us giving immunizations to the kids. Our technique and the pain definitely improved. Its really not the pain issue, because there are certain serums that are going to hurt regardless of how you give them. Particularly the MMR (measles, mumps and rubella) is pretty painful, so routinely, thats the last one you give. If you give that one first, the childs not going to let you give anymore. Normally, with a shot system, kids are crying and screaming with the MMR with a needle system. But when we do the MMRs with the Biojector, most of the kids would react more like ow and not the screaming.
Some nurses were at first resistant to change, but eventually fell in love with it, Denny says. We started out with one, and we now own six. You draw up whatever vaccine it is into this Bioject syringe, and we usually pre-draw those for a big clinic. You have them all stored and ready to go, so when we have a clinic, we bring a child in, see what they need, pull out the correct syringes, have one Biojector and just give a shot, reload, give a shot, reload. When we had these big clinics at our biggest, we did about 140 kids and gave more than 500 immunizations we had all six Biojectors. Now our immunization rate overall is 97 percent. That was in three or four years. The first year, we went from 20 percent to 70 percent. I firmly believe the only way we accomplished that was with this system. Because we were able to do the kids quickly, instead of having five nurses available one to give the vaccine and four to hold we had five nurses giving vaccines.
Many more facilities may have looked at the Biojector and shunned it because the initial price appears unreasonable. But, Denny says, accounting for the big picture and all other costs associated with a needle system, Its worth the initial outlay. We calculated what one needlestick cost, in terms of workmans comp expenses, going for the prophylaxis, getting tested repeatedly, and it more than paid for itself right there. When you look at other factors that you cant put a monetary value on the success with the kids, and prevention of communicable diseases you cant put a number on that, but thats a huge issue. For instance, Arizona had the highest rate of hepatitis A in the world. This was just a couple of years ago, and on our reservation, we had cases of hepatitis A all the time. Right now, the state law on hepatitis A states that the vaccine should be given to kids ages 2 to 5 in Maricopa County only, because thats where the bulk of the hepatitis A cases were. But we decided every school-age child was going to get the hepatitis A vaccine, and we have not had one case of hepatitis A in two and a half years on the whole reservation.
The Biojector is safer for my staff, agrees Karen Newmark, RN, clinical coordinator of the primary care clinic at Childrens Hospital of Oakland in California. At a place where you have to give five vaccines at a time, you just line up Biojectors and youre not dealing with needles and caps and sharp things. Its a time saver; its a safety thing; theres the whole psychological thing with some of the older kids not seeing a needle. This is a primary care clinic, so its all kids. We have kids that are often behind on immunizations, so its very common to give five vaccines at a time. We have a huge clinic population, so were very busy; during our busy season we can give more than 100 shots a day. So you just want to make it as safe and fast as you can.
The primary care clinic at the childrens hospital is the only area of the facility that uses the needle-free system. Asked why it hasnt been adopted elsewhere, Newmark posits, I dont know that its worth their while; a lot of places dont give many intramuscular injections. Theres a whole education thing, and where you keep it, dealing with the CO2 cartridges but for us, it makes all the sense in the world. Its certainly safer for the staff, putting the whole kid part aside.
The clinic utilizes a safety lancet, the BD Genie Lancet. You see nothing sharp; you push down with your thumb, and this trigger device goes in and out, and you never see it, but somehow theres a hole. Its awesome. They have a pediatric size and a bigger size, Newmark observes. We adapted that product three years ago (after the needlestick), plus we were getting word from the safety committee. Materials management wanted us to get rid of all the nonsafety items.
Convincing the staff to adapt the new product was a non-issue, Newmark says. I told them Im the boss, she jokes. On the one hand, we implement the policies, but more importantly, its about safety for them, and you always lead your conversations with that. I want nothing but safety for them. Were always looking for ways to improve safety for the staff. I think the important thing is to let your staff know youre doing this to keep them safe. Ive been stuck with a needle probably three times in my career. Its not fun; its really scary for that to happen.
Your chances of getting stuck are basically zero, points out Alan Weisshar, MD, of the Torrance Pediatrics Group in Torrance, Calif. We do have needles in the office that we use for TB skin tests, and injections that are Depo that you cant give with Bioject, but thats it. Personally, I give 90 percent to 94 percent of the shots in the office. Ive been doing this for 25 years, and Ive gotten stuck about five times, probably once every four or five years. Its always when you have to give multiple injections, which is what a pediatrician has to do youre giving from two to four injections per kid, the kids moving, youre trying to work fast to reduce the crying, and you have your standard of what you do with your used needle when youre done, but your hand gets pushed or something moves or you turn your head in the other direction. Its always when youre rushing. And now, I just dont have that risk, he explains.
The Biojector, he says, is a much nicer injection. Pain is very highly correlated to the material some vaccines are very painful and some vaccines arent. But when you inject with a needle, you inject with one point and make a little ball. When you inject with a Bioject, it goes through the skin as a stream but disperses, and the surface area is 15 to 20 times greater than the absorptive surface area if you were injecting with a needle which means your take rate for vaccine is much higher, and thats why you cant use it with Depo medication. If youre giving something like Depo-Provera, which is given for contraception every 90 days and you give it with a Biojector, the absorption is so rapid and so complete that its gone in 60 days. The absorption of medication is much more efficient. The patient kindness is much greater, he adds.
Another product that has shown great potential is the Lasette from Cell Robotics. The Lasette is a capillary blood sampling device that produces a fingertip wound by laser ablation. United Blood Services (UBS), a national blood banking service, performed two pilot studies of the device and is now evaluating it in several other centers.
The results from the first study were performed at a center in Albuquerque, N.M., says Elizabeth Waltman, executive director of UBS at that location. Once the results were submitted to the corporate office, they made the decision that they didnt have enough information in order to go forward with everybody using the Lasette, so I believe they chose three locations to use the Lasette, and we were not one of them. I think one is Lafayette, and one in Tupelo, and one in Rapid City.
The two studies in Albuquerque evaluated donor comfort and the quality of the samples. In the first pilot that we did with the blood donors, the majority liked it better; it didnt hurt as much and it didnt hurt as long, Waltman says. The thing they didnt like was the smell. If you remove the Lasette too quickly, theres a plume of smoke from the laser; it smells like when you burn hair, which is offensive. The trick is to keep the Lasette close enough long enough so the plume doesnt come out right after the Lasette sticks the finger.
The objection from the staff side [is related to] the way the Lasette is made right now. The Lasette was set up for people to stick their own fingers. When someone else is doing it, its kind of an awkward angle. It can be mastered, but for people or centers that have never used it before, that could be something that may be a point of contention. We also asked Cell Robotics to change the settings; the Lasette originally had settings from zero to 10, and we were concerned about staff moving it up to the 10 mark, because that would be necessary very rarely. We asked them for settings of low and medium, with no high, and they did that, she says.
The next study we did was for the quality of the sample, and how many more donors would be allowed to donate using this. What we discovered was that a significant number of donors would be allowed to donate using the Lasette who wouldnt have donated using the lancet. Also, if the donor doesnt pass the copper sulfate test, then we do the spun hematocrit, and we found the quality of the sample was better, so more people passed the initial copper sulfate and didnt have to be spun, Waltman offers. Of course, the other thing is that there are no sharps.
She adds, At the AABB (American Association of Blood Banks) conference in Baltimore this past year, Cell Robotics had a booth set up. I thought it was really interesting that people were standing in line to get a finger stuck. And after they got stuck, they were going back and getting friends of theirs to come and get their fingers stuck. These are blood bankers, laboratory managers, administrators, anybody involved in the blood banking industry. I think even some of the vendors were coming over and getting their fingers stuck.
Waltman concludes, I really think its a terrific device. Whether or not we use that device, my thought is that the blood banking industry as a whole is going toward doing things that will make the donor more comfortable in the process of donating blood anything that is financially within reason and yields the results were looking for as far as more donors being able to donate, and donor retention. The blood banking industry will be giving those things a hard look and incorporating the devices that help them meet those ends.
Other facilities are adapting more conventional sharps safety devices; however, due to a lack of employee cooperation, these may not be as successful as hoped.
Prior to my arrival, the hospital had a committee called the sharps injury prevention task force that was looking at the implementation of different safety devices, says MaryAnn Gruden, CRNP, COHN-S/CM, coordinator, employee health services at the Western Pennsylvania Hospital in Pittsburgh. We switched over to some safety devices, and in the last year, weve actually restructured our entire employee injury prevention program. Now that task force is part of the subcommittee for our Work Safe program. In spite of all our safety sharps, we still have not seen a significant decline in our sharps injuries, she relates.
This group used to meet quarterly; now they meet every month. Probably two years ago, we really started following up with our managers if theres been an unsafe practice in an exposure, say, somebody didnt activate the safety feature, or there was improper disposal. When that occurs, we contact our education department representative and the nurse manager, and then theres follow-up on that end.
The environment makes the risk much greater; the Western Pennsylvania Hospital is a teaching hospital with a large population of residents. Our clinical nursing staff is the biggest group that experiences needlesticks; our second biggest group with needlesticks is residents, Gruden reports. Weve struggled with what to do with them. In December 2004, we decided to involve the physician program directors, so any time any kind of significant exposure occurs with one of the residents or medical students, their physician director gets a memo from our office. It says what happened, what they were doing, how they were counseled, and we ask the physician director to get us feedback. Weve had a pretty good response from that, surprisingly, because we didnt know what to expect. They have given us feedback, and seem to be taking that seriously.
In the last six months, the sharps committee has taken to reviewing all sharps injuries or significant exposures that are reported to employee health. Thats confidential; there are no names listed, but we describe the event, and see if theres anything else we can intervene on, she says. The facility incorporates as many safety devices as possible BD SafetyGlide syringes, Braun IV catheters, safety blood gas tips, safety butterflies, etc. The hospital is in the process of transitioning from a BD butterfly that has a sheath on it to their push-button retractable phlebotomy butterfly. We have a number of needlestick injuries related to trying to activate the safety feature on the butterfly, Gruden points out. Well also look at safety scalpels in the operating room. Were also looking at BDs retractable syringes, the Integra syringe, because we still have needlesticks related to IM (intramuscular) and subcutaneous injections. We used those retractable needles when we did the flu campaign in the fall. With the shortage of vaccine, we were trying to stretch our vaccine, and with the Integra syringes, because theres less dead space, you can actually get more doses out of the vial. We want to at least evaluate whether theyre appropriate, if not house-wide, but in certain departments. I feel like in the last year, weve done more with our sharps program, and maybe a year from now, I can say weve really seen a significant decline.