By Kelly M. Pyrek
Ten years ago this month President Bill Clinton signed into law the Needlestick Safety and Prevention Act (NSPA), designed to make more specific the requirement by the Occupational Safety and Health Administration (OSHA) that employers identify, evaluate and implement safer medical devices, especially addressing occupational exposure to bloodborne pathogens from accidental sharps injuries in healthcare and other occupational settings. The legislation, in this modification to OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030), also mandated additional requirements for maintaining a sharps injury log and for the involvement of non-managerial healthcare workers in evaluating and choosing devices. OSHA's Bloodborne Pathogens Standard applies to all employers who have employees with reasonably anticipated occupational exposure to blood or other potentially infectious materials (OPIM).
One might expect that the NSPA significantly contributed to the reduction of sharps-related injuries in the healthcare setting, and it has, at least judging by a cursory look at data from the EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Network. In 2001, a total of 1,929 percutaneous injuries (PIs) were reported by network facilities; in 2007, the year for which the most current data is available, in 2007, a total of 951 PIs were reported. While any reduction in PIs is considered to be a victory, healthcare professionals are urged not to become complacent about the approximately 1,000 sharps-related injuries that occur every day and the numerous ones that are not reported. In a 2008 study of 700 nurses views on workplace safety conducted by the American Nurses Association (ANA), nearly two-thirds (64 percent) of respondents say needlestick injuries and bloodborne infections remain major concerns, and 55 percent believe their workplace safety climate negatively impacts their own personal safety.
One expert who has long served as an advocate for the occupational health of care providers is Mary Foley, RN, MS, PhD, past president of the ANA and associate director of the Center for Nursing Research and Innovation at the University of California San Francisco. Foley says the 10th anniversary of the NSPA is cause for celebration but emphasizes that there is so much more work to be done to address needlestick and other PI prevention.
Foleys passion about preventing occupational risk was fueled in the 1980s when she was working as a staff nurse at Saint Francis Memorial Hospital in San Francisco, one of the first hospitals to care for a patient infected with Acquired Immune Deficiency Syndrome (AIDS).
"We were challenged by a very mysterious, life-threatening illness where patients had high fevers and strange spots, and it was a real conundrum," Foley says. "We were just doing our jobs as nurses, caring for these patients without worrying about ourselves being exposed to infectious disease. As an early advocate for nursing and for patient safety, I got involved quickly in the possible implications of this phenomenon we were experiencing. Suddenly, some of our co-workers were becoming ill and a pattern was emerging that was devastating to San Francisco, then eventually the U.S. and around the world."
Foley says that living through these events propelled her professional advocacy to protect staff from accidental injury, and to provide safe, non-discriminatory care to patients in a national policy arena. Foley worked with June Fisher, MD, a clincal professor at the UCSF School of Medicine's Division of Occupational and Environmental Medicine, to spearhead a campaign in California for the first state law in the U.S. to address safer product design. The California legislation was the first in a series of state efforts to reduce accidental injury and to address safer medical device design. Foley's advocacy efforts escalated in 2000 when she was elected ANA president and was actively involved in the national efforts to amend the federal OSHA laws to improve worker protection from sharps-related injuries. "I collaborated with advocates in infection control and occupational safety, and with unions, to successfully guide the Needlestick Safety and Prevention Act of 2000 and, 10 years ago was honored to be in the White House when the legislation was signed by President Clinton," Foley says.
The early days were also some of the darkest days, Foley recalls. "Within my professional group I was tapped to respond to some of the emerging policy issues on AIDS and infections, and the precautions that should be used in the work environment in what was soon revealed to be a transmissible disease. I had a chance to sit on congressional panels and try to project a real-world view of the issue, including devastated families and worried staff. Our position was you dont attack this by attacking the people -- we didnt quarantine, we didnt support widespread testing because it led to terrible discrimination and personal physical threats. It was a very negative climate at the time." Foley continues, "We advocated for common-sense, practical approaches; it was clear this was a bloodborne pathogen and things like gloves could help protect healthcare providers. I get queasy thinking about the things we did without gloves at that time, including putting in IVs and changing dressings. Gloves were relatively scarce and used only in the sterile field. We were hoarding gloves because there was a shortage."
Foley credits her facility's infection control nurse who was active in her state APIC chapter who quickly understood that basic infection control strategies could reduce risk, and who advocated for needle-disposal boxes being installed in each patient room. "It was a huge step forward in us not carrying exposed needles down the hallways, and all of the other craziness that had been the standard for disposal in those days," Foley says. Foley joined other advocates to better train more than 100,000 healthcare workers across California in the 1980s, which put the state well ahead of the curve in the years preceding the NSPA. Foley says her work for the ANA "opened my eyes to the worker-safety perspective of an evolving disease of international importance." She adds, "I think there are always two sides of safe care there should be protection for patients as well as healthcare workers."
It's a balanced safety agenda that Foley says must be present in all healthcare institutions, especially due to the self-sacrificing nature of healthcare professionals who frequently put their safety needs behind those of their patients. For this reason, Foley says she is a strong supporter of the online community, Safe in Common (safeincommon.org), designed to bring educators and healthcare professionals together to address sharps injuries. "I am proud to be a part of Safe in Common because the dialogue is so valuable," she says. "Sharps safety has fallen off the radar and there is a complacency to the extent that there will probably be a resurgence in injuries simply because there is no one to strongly advocate for and teach safer methods and better use of technology. There is stagnation out there, in that new sharps-safety devices aren't embraced enthusiastically because busy, overworked staff cant cope with anything new, even if they would be safer for doing so."
Foley says this situation is understandable, given human nature coupled with the frenzied pace of healthcare delivery these days, but points out, "It can be very hard to remember to be safe; if you have to remember to be safe you are likely not to be." Foley says that for her dissertation she reviewed the work of Dr. William Haddon who was an early proponent of passive protection in the automotive design industry. "He said seatbelts wont work because people dont buckle them, so install airbags instead. He said you had to 'crash-proof' people so that they didn't have to actively think about their safety. People aren't bad for not taking this extra step, they are just human. I think that applies so well to who we are as healthcare workers -- we are concerned about others and are very likely to put our own needs secondary." Foley continues, "Thats a wonderful work ethic but it can cause serious harm. I still know people who recap needles; new grads say they have never been taught any other way to use this syringe than to activate the safety device and dispose of it immediately. When I saw my first safety needle, my immediate instinct was to put a cap on it. Where did that come from? Its the desire to protect others over the protection of self."
As we have seen, the goal of the NSPA was to mandate certain safeguards to help counter those very inclinations that Foley mentions. But it's an unfinished agenda, she says, and adds that clinicians must examine if they are fully implementing the intent of this law. In addition to what was already required by the 1991 standard, the NSPA requires the documentation of annual consideration and implementation of appropriate engineering controls, and solicitation of non-managerial healthcare workers in evaluating and choosing devices. The plan must be reviewed and updated at least annually.
"If you look at the purchasing patterns, it's clear that safety devices are being purchased in large amounts," Foley says. "And the minimal standards are probably being met in most institutions. Facilities realized that they had to introduce devices that were better than what they were using previously in order to be compliance with OSHA. What I worry about, and what we have heard anecdotally, is what is happening to the annual exposure control plan, the annual review of the latest products on the market that better meet the needs of staff. The NSPA requires that clinicians weigh the clinical effectiveness with patient and worker receptivity to the device. I also would guess the needlestick safety committees that were to oversee needle safety have probably waned in facilities and that healthcare workers are not being involved in ongoing evaluation of new products. It is the full intent of the law to bring safer devices into the environment to improve the frontline worker's safety and enhance their expertise in the work they do and the devices with which they need to do it. When you dont engage them in product evaluation and selection, you are probably staying with the devices you already have. These devices may meet the minimum standard but they may not reflect the next generation of safety improvements. These issues require champions and Im not sure there are enough champions keeping these issues alive."
Foley advises, "Take a look at your safety agenda and whenever possible, align it for both patients and for staff. Being consistent throughout your message and the priorities that you set will allow you to accomplish more than when those items are done separately. Review the intent of the law and look carefully at your current commitment to the annual review of the exposure control plan -- when was it last visited? Have new procedures been introduced? Have those gone through protocol? Has your needle safety committee met? If not, get them together and ask them what they need are they satisfied and safe? Look at the numbers carefully do you have good reporting? Are you getting good reports of near-misses? Are people telling you why they were injured? What products or practices are leading to those injuries? How are new people taught? Dont assume they understand the importance of using the safer device or actually knowing how to use the device assess them as an annual competency. Knowledge drops off with time, so its an opportunity to re-educate and reaffirm for people the importance of understanding how to use the devices as safely as possible. Have some focus groups with frontline workers and ask them how its going, what they finding in terms of safety on the floor go through situations when products and practices put people at risk. Be sure to provoke responses because this is the perfect time to remind people of what we have accomplished with the NSPA and introduce newer people to the magnitude of this activity and the value they have in their life from being better protected than the previous generation."
Foley says healthcare professionals must refocus on sharps safety a decade after the NSPA. "People seem to have moved on to new agendas. That's not surprising, seeing that there are new sheriffs in town, like CMS, telling you that care related to HAIs and adverse events is not going to be reimbursed -- that's what is grabbing the attention and demanding the resources. Among those concerns, why arent we adding HAIs among hospital employees, such as hepatitis B?"
Foley says there must be a renewed commitment to teaching and practicing sharps safety-related techniques, as well as a dedication on the part of manufacturers to continue developing new safety devices. "Facilities no longer have needlestick safety at the top of their list of priorities; they are not allowed to as they first have patient safety initiatives to maintain. Worker safety in many places is lagging and that deeply concerns me. Patient safety and healthcare worker safety must be aligned, and both sets of experiences should be measured and monitored and constantly improved upon. I think if we unified safety and made it a universal message, we would reinvigorate the worker-safety part of the work that needs to be finished. What we accomplished 10 years ago is great but I am not satisfied with the status quo and our work its not close to being over yet."