Infection Control Today - 07/2003: Getting the Point of Sharps Safety

Getting the Point of Sharps Safety:
Veterans Administration San Diego Healthcare System Wins 2003 NAPPSI and ICT Primary Prevention Safety Award

By Brad Poulos

The Primary Prevention Safety Award is sponsored by the National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI) and Infection Control Today. The award recognizes a healthcare facility that has demonstrated efforts to prevent sharps injuries and champion primary prevention techniques and technologies.

Since 1982 the Veterans Administration San Diego Healthcare System (VASDHS) has been using a variety of sharps safety products housewide with a particular focus on using primary prevention technologies (i.e., eliminate the needleeliminate the risk.) The depth and breadth of actions to minimize sharps injuries at this facility demonstrate an extremely proactive and effective sharps-injury reduction program that focuses not only on healthcare worker (HCW) safety, but also patient safety, improved productivity and demonstrated cost savings.

The facility prides itself in setting the standard of care for the community in sharps injury reduction products and programs. Clinicians are strongly encouraged to bring to the administration any and all safety products, ideas or suggestions that will help reduce any remaining sharps injuries. The facility has a standing safety products committee that meets monthly to review sharps-injury reports and statistics, conduct root cause analysis and continually look for improvements in sharps safety.

The culture to minimize sharps injuries goes beyond the frontline HCWs. Outstanding educational efforts include not only frontline HCWs, but also downstream non-users in the housekeeping and dietary departments.

Because of its affiliation with the University of California at San Diego Medical School, there is close interaction with the dean of student affairs to require all medical students, interns and residents to complete a sharps safety workshop before entering the hospital. Innovative programs include a 24-hour Needlestick Hotline for employees who sustain a sharps injury to call for consultation; a 1st Dose anti-retroviral HIV kit to be used immediately after a high-risk injury; bi-weekly safety committee departmental internal rounds allowing coverage of the entire facility twice each year; and a proactive approach at full implementation of all safety products wherever possible.

In addition to carrying sharps-injury protection to the staff within their own local healthcare system, VASDHS is part of the Veterans Integrated Service Network (VISN 22), a VA network of five hospitals and 30 community-based clinics. The VASDHS takes a lead role at VISN meetings to share sharps-injury reduction programs, thereby impacting thousands of clinicians within the network.

VASDHS has 238 hospital beds, including skilled nursing beds, and operates several regional referral programs including cardiovascular surgery and spinal cord injury. It is affiliated with the University of California, San Diego School of Medicine and provides training for 809 medical interns, residents and fellows, as well as 64 other teaching affiliations for nursing, pharmacy, dental and dietetics.

VASDHS has one of the largest research programs in the VA nationally, with a budget of more than $47.2 million (FY 2002), 220 principal investigators and more than 965 projects. VASDHS is also home to several specialty research programs including Health Sciences Research and Development (HSR&D), Mental Illness Rehabilitation, Education, and Clinical Centers (MIRECC), the Research Center for AIDS and HIV, and the San Diego Center for Patient Safety.

As noted, VASDHS is part of the Veterans Administrations Pacific Healthcare Network (VISN 22), which is comprised of five hospitals, 30 community-based clinics, 690 physicians, 1,700 registered nurses and 9,500 full-time equivalent employees. The five VA hospitals in this network are located in Los Angeles, Long Beach, and Loma Linda, Calif. and Las Vegas. Combined, the network hospitals operate 1,905 beds including 917 acute, 639 nursing home, 321 domiciliary and 30 psychiatric residential beds. More than 700 medical residents and thousands of nursing and allied health students are trained in network facilities each year.

The primary prevention technologies implemented include: sutureless catheter securement products, needlefree access valves, pulse oximeters, surgical glues in dermatology, needleless IV products, needleless drug delivery products, needleless hemodynamic monitoring, prefilled syringes and plastic blood collection tubes.

Using primary prevention technologies wherever possible is a constant goal at this facility. Even before the passage of the Needlestick Prevention Act of 2000, the materials management group immediately recognized the value of using catheter securement devices as a way to not only reduce sharps injuries from suture needles and IV stylets, but to also improve patient safety, improve healthcare workers productivity, and reduce costs. The use of StatLock® IV catheter securement devices, packaged with the Alaris® Smartsite Needlefree System, provides an example of combining two primary prevention technologies, along with the use of a secondary prevention technology (a safety IV catheter: J&J ProtectIV®) to maximize HCW safety. This forwardthinking approach was recognized in 1999 by a local television station in a feature focusing on improving healthcare delivery in the community.

Wisely, by analyzing the cost of a needlestick injury, versus the increased cost of a safety device, this VA system decided it was less expensive to prevent the needlestick injuries than to treat them.

Secondary prevention technologies implemented include: safety IV catheters, safety syringes, safety blood collection devices, safety lancets, safety scalpels and safety biopsy needles.

As long ago as 1982, the VASDHS analyzed where the most frequent needlesticks were occurring. Blood Glucose tests needles were the number one source. They then evaluated three different safety products. After evaluation, they selected one device and converted 100 percent of the blood glucose test needles to the safety product. In the first year following implementation the VASDHS saw a reduction of 22 needlesticks, or approximately 80 percent.

Training and education to prevent sharps injuries begins with all new employees. In using safety devices, the clinician not only needs to know how to use the device, but also must have a competency with the device. Recognizing this, all new nursing education classes include practice sessions to make each nurse comfortable and competent with the new products.

The VASDHS is a teaching hospital, with residents, interns and medical students rotating through. Before any medical student, resident or intern is allowed into the hospital, they must attend a needlestick safety workshop that instructs them on policies and products available. They also learn policies and procedures on reporting needlestick injuries. The medical students are also required to attend an infection control orientation prior to coming onto the hospital grounds. This type of educational approach is the unique result of collaboration between the dean of student affairs at the medical school and the VASDHS infection control practitioner.

In the ICU, there is a product board with all the sutureless securement products displayed so as to educate the staff on what specific products are available to replace sutures.

Even before the passage of the Needlestick Prevention Act of 2000, this facility was an early adopter of many new sharps injury prevention technologies. Eliminating sharps injuries wherever possible is a constant theme at VASDHS. There is a monthly review of all reported needlestick injuries within the safety committee to conduct a root cause analysis and looking for methods for performance improvements (i.e., prevention analysis). Any performance improvements are then conveyed to all applicable staff meetings to prevent further occurrences. Members on the safety committee include clinical staff from high-risk areas (OR, ICU, PACU, outpatient) as well as infection control, employee health and materials management.

As an example of their commitment to employee involvement with sharps injury prevention, when the hospital was puzzling over where to put sharps disposal containers, they asked for the staff to tell them where they felt the best locations were. To determine the height of the containers, they had the shortest nurse set the height, so as to accommodate the shortest staff members. This is an excellent example of involving the front line HCWs.

The concern for downstream injuries (non-users) is paramount at this hospital. An example is in the dietary department where sharps injury risk can come from sharps left on dining trays or plates. The VASDHS has put sharps containers in the dietary areas. They also trained the dietary staff on how to properly pick up napkins so as to avoid a sharps injury, should there be a sharp under the napkin. Further, they trained the dietary staff to report any exposed sharps on the dining trays immediately to the staff nurse, who could then track down who left the sharp exposed. This same training was applied to the housekeeping and laundry staff.

The VASDHS has an annual sharps safety fair and training for the medical as well as the animal research staff connected with the university and hospital.

The VASDHS operates a Needlestick Hotline, staffed 24/7 for employees who get a needlestick injury. The hospital infectious disease doctor is also on call 24 hours a day for counseling on high-risk needlestick injuries. As mentioned above, the VASDHS has created its own first dose kits. These are used in the ER, homecare and satellite offices and offer anti-retroviral medications for prophylactic treatment of HIV, post needlestick injuries.

The safety committee routinely (twice a month, covering every department twice a year) does internal rounds to identify sharps safety improvement areas. A recent example was the identification of overfilled sharps containers. This observation resulted in a policy change as to the changing frequency of the containers, including designating who and when, calling for a clear delegation of responsibility.

The NAPPSI Clinician Advisory calls upon clinicians to employ both primary and secondary prevention measures to maximize sharps injury protection in the healthcare workplace. Clearly, the VASDHS has taken the spirit of the advisory to heart. The implemented and reinforced primary prevention strategies were adopted long before they became mandatory under federal law. As a result, thousands and thousands of sharps have been kept out of the VASDHS workplace. And countless sharps injuries have doubtless been prevented.

The secondary prevention strategies have rendered what sharps the VASDHS must employ safer. The constant staff input and staff education has created a safety environment at the VASDHS that is second to none.

Congratulations to the Veterans Administration at San Diego Health System for their wise and widespread implementation of sharps injury prevention. Clearly, the VASDHS has earned the first-ever Primary Prevention Sharps Safety Award.

Brad Poulos is deputy director of the National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI).

Education, Policy, Prevention: Employee Health Team Protects Workers from Needlesticks

By Kelli M. Donley

University Health Care System in Augusta, Ga., was ahead of the curve when hospital administrators began pushing for safety devices in the early 1990s. Today, employee health manager Rosemary Dudley, RN, says this insight gave her team an edge to protect their 3,500 employees from needlesticks.

We used posters showing actual pictures of people who were involved in injuries, Dudley says, describing the systems education methods. The posters showed the three steps (employees should take after a possible needlestick) and we put them in areas where the workers are. That is what raised their awareness.

This three-step approach written in Universitys policy includes immediately notifying a supervisor when potentially stuck by a needle, cleaning the wound site properly and contacting employee health.

We also have educational videos house-wide and for management, she says. We started on these right before the law came out.

We knew it was coming. We stay on the cutting edge. We dont want to backtrack; we try to do the right thing from the get-go. We really started in the early 1990s with needleless tubing and needleless access.

The healthcare systems proactive approach to education, new product installation and policy-making has significantly reduced the number of needlesticks and garnered national attention. University was selected as the 2003 runner-up in the Primary Prevention Sharps Safety Award sponsored by the National Alliance of the Primary Prevention of Sharps Injuries (NAPPSI) and Infection Control Today.

Dudley says one element of the healthcare systems approach to protecting employees includes piloting new products. In 1999, employees participated in a trial study of Premiers Safety Glide Needle. Dudley says such opportunities give healthcare workers the opportunity to voice their opinions about new products, which in turn motivates the manufacturer to continue brainstorming for even safer technologies.

New products are continually getting better and better, she says. We do have challenges in training. At large hospitals, when a new device comes in, the first thing you do is you look at the product. Then you pilot it on the different floors where you think it may work. When you pilot it, the frontline workers decide if it is going to work and they give you great input you can take back to the manufacturers. Then theyll come back with something even better.

Some devices the system has piloted and used include: Interlink Needless IV Access System, Johnson and Johnson Protectiv IV Access, Vacutainer Safety-Lok blood collection, disposable retractable safety scalpels, blood transfer devices, blood culture collection adapters and inserts, filter straws and blunt 18-gauge fill needles. The systems decision to pilot new safety products, Dudley says, are in part responsible to the significant decrease in employee needlesticks. Data provided by University shows 103 reported needlesticks in 1997 in comparison to 77 in 2002.

Another challenge to providing the safest working environment for employees, Dudley says, is getting those same employees to follow these policies and use new devices can be difficult.

Training and acceptance are some big hurdles for us, she says. People dont like to change. When they get proficient with one device, they dont want to move to a different one. Even though we can see that the device may work better if they would just try it, take their time with it at first and get used to it, sometimes there is resistance.

With fervor, Dudley recognizes her work will never be done. Im in the middle of all of it, she says. Im always asking, Are we always doing as good as we can? Our focus is prevention we want to prevent it from ever happening.

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