Infection Control Today: IC Business

April 1, 2005

Smart Sharps Evaluation
Making a Case for Change

By Kathy Dix

Introducing a new sharps-safety device to yourfacility takes more than just purchasing the product and making it available;you must often create a committee to review possible replacements for primaryand secondary sharps injury prevention devices. The committee must narrow thefield of options, test the devices in various departments in the facility, getfeedback from end users, purchase the item, inservice employees on its properuse, 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 thevariables 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 ofcontainers we were going through in a period of a week, and how many needles andsyringes we went through, how many red boxes we went through, how much that wasgoing to cost to process by the maintenance crew, the frequency of having themchange the boxes and empty the red trash, she says.

Then we compared that against the SafetyGlide. I do use that as well. Butvery few people use them; mostly its for LVNs and RNs, because were mixingmedications. I chose to go with the Biojector. We thought it was going to be astronomically unattainable in a communityhealth 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 didntlook 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 couldget Biojectors, Davis recalls.

After we were mandated to go with a safety device, we did the costanalysis on it, and it was because of the large volume that we do. We give morethan 20,000 to 22,000 immunizations per year. When I did the cost analysis, there was no red trash, and there was a bigchunk off it right there. That helped ease the pain of the cost of theBiojectors. Kurt Lynam [at Bioject] was so good to work with, he was so helpfuland 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 gavethree 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 hereis vaccine (flu shots and pneumovax), so it works well for us.

Davis facility has many medical assistants giving shots who are notlicensed nurses and therefore must be trained, retrained and made proficient inusing needles. During that cost analysis, I calculated how much it cost usfor two needlesticks that year. With the costs of the red trash and theneedlesticks and we process needlesticks in-house, so its less cost thanif we had sent them to the hospital and the volume of shots we were going togive, it actually turned out to be a little less expensive to use the Biojectorsand it was totally safe. We have not had a needlestick since; in the nursingdepartment, we have totally eliminated the needlesticks for about four years,she reports.

Weve had a lot of training, because you have to perfect your techniqueso you do the most painless shot. It does pierce the skin and has somediscomfort to it. Here, we give up to about eight shots to one child on the sameday, 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 shotand then would come back for a booster and we didnt have the Biojectoranymore. Theyd say, I dont want the needle; I want the Biojector. Wedsay, Were thinking of buying them, but we dont have them yet. Thekid 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. Thatwould probably be a person who had a bruise. That has happened to one of our ownMAs when we were trying it out on each other, but I believe that was lack ofperfection in the method, she says. I had the Biojector training nursecome down from Oklahoma; shes been here on three different occasions. Thelast time I brought her because we had a fairly big turnover in staff, and Ithought it would be best that she give everyone a thorough going-over. I used tohave a little trouble with one medical assistant in particular; she really didntwant to use the Biojector. She was finally told, You are not going to haveneedles, so she had to use the Biojector. Every 18,000 shots, you have tosend the Biojector in for an overhaul. I told her, Its going to have to goin for repair, and she practically hugged it, and asked, How long is itgoing to take to come back? They promised one to replace it while it wasbeing fixed, so she was OK with that.

Other facilities have also had success with the Biojector; one of these isGila River Healthcare Corp. in Sacaton, Ariz., which provides quality healthcareto 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, saysprogram manager Cathy Denny, RN, MSN, FNP-C. Weve kept a coupledemonstration syringes, to prove to the older kids in middle school and highschool that theres no needle, because theyre not quite sure they believeus.

When the program first started nearly seven years ago, the immunizationcompliance rate for schools in the Gila River Indian Community was approximately 20 percent. We were looking at ways to improvethat. Because its a reservation, theres a lot of poverty here, andtransportation 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-freesystems and the Biojector, so we checked it out and decided that was the way togo for several reasons. It promised to be a faster method when werelooking at upgrading 3,000 kids on their immunization status, we gave a lot ofshots 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 theschool kids, but if the parents wanted to bring younger kids there, wed dothem, too. We were giving sometimes five and six shots I use the termloosely and nobody would have to hold down the kid. You didnt have thischild thrashing around.

The risk of getting stuck with a contaminated needle was extremely high usingneedles, even the safety needles, because perhaps the child moves, bumps yourarm, and you end up giving the shot to the person next to her. Wed be at aschool doing a clinic, and even though it was not time for their shots, somekids 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 kidsthat wed given vaccines with the needle-free system at school whose parentswould bring them into the clinic. The employees would try to give them theirshot with a needle, and theyd scream, I want the gun, even though wenever called it a gun. Wed have to go over there to give it to them with theneedle-free system, she adds.

It really was a tremendous success with the kids. If you look at thesyringes themselves, theyre a little bit more expensive than the standardsyringe and safety needle system, but when you add in the fact that you donthave to utilize sharps disposal, because theres no needle that can go in theregular garbage, that cuts costs. We figure that if you had one positiveneedlestick, that would pay for years of syringes, Denny points out.

To evaluate the product, she and another nurse practitioner tried theBiojector with saline on each other. Because they hadnt been trained in itsuse, 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 atrainer come out on the first day, and then we had a clinic scheduled the nextday. She went out with us and did handson training with us giving immunizationsto the kids. Our technique and the pain definitely improved. Itsreally not the pain issue, because there are certain serums that are going tohurt regardless of how you give them. Particularly the MMR (measles, mumps andrubella) is pretty painful, so routinely, thats the last one you give. If yougive 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 needlesystem. But when we do the MMRs with the Biojector, most of the kids would reactmore like ow and not the screaming.

Some nurses were at first resistant to change, but eventually fell in lovewith it, Denny says. We started out with one, and we now own six. You drawup whatever vaccine it is into this Bioject syringe, and we usually pre-drawthose for a big clinic. You have them all stored and ready to go, so when wehave a clinic, we bring a child in, see what they need, pull out the correctsyringes, 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 gavemore than 500 immunizations we had all six Biojectors. Now our immunizationrate overall is 97 percent. That was in three or four years. The first year, wewent from 20 percent to 70 percent. I firmly believe the only way weaccomplished that was with this system. Because we were able to do the kidsquickly, instead of having five nurses available one to give the vaccine andfour to hold we had five nurses giving vaccines.

Many more facilities may have looked at the Biojector and shunned it becausethe initial price appears unreasonable. But, Denny says, accounting for the bigpicture and all other costs associated with a needle system, Its worththe initial outlay. We calculated what one needlestick cost, in terms of workmanscomp expenses, going for the prophylaxis, getting tested repeatedly, and it morethan paid for itself right there. When you look at other factors that you cantput a monetary value on the success with the kids, and prevention ofcommunicable diseases you cant put a number on that, but thats a hugeissue. 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 ofhepatitis A all the time. Right now, the state law on hepatitis A states thatthe vaccine should be given to kids ages 2 to 5 in Maricopa County only, becausethats where the bulk of the hepatitis A cases were. But we decided everyschool-age child was going to get the hepatitis A vaccine, and we have not hadone 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, clinicalcoordinator of the primary care clinic at Childrens Hospital of Oakland inCalifornia. At a place where you have to give five vaccines at a time, youjust line up Biojectors and youre not dealing with needles and caps and sharpthings. Its a time saver; its a safety thing; theres the whole psychological thing with some of the older kids notseeing a needle. This is a primary care clinic, so its all kids. We have kidsthat are often behind on immunizations, so its very common to give fivevaccines 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 wantto make it as safe and fast as you can.

The primary care clinic at the childrens hospital is the only area of thefacility that uses the needle-free system. Asked why it hasnt been adoptedelsewhere, Newmark posits, I dont know that its worth their while; alot of places dont give many intramuscular injections. Theres a whole education thing, and where you keep it, dealing with theCO2 cartridges but for us, it makes all the sense in the world. Itscertainly safer for the staff, putting the whole kid part aside.

The clinic utilizes a safety lancet, the BD Genie Lancet. You see nothingsharp; 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 apediatric size and a bigger size, Newmark observes. We adapted that product three years ago (after theneedlestick), plus we were getting word from the safety committee. Materialsmanagement 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 implementthe policies, but more importantly, its about safety for them, and you alwayslead your conversations with that. I want nothing but safety for them. Werealways looking for ways to improve safety for the staff. I think the importantthing is to let your staff know youre doing this to keep them safe. Ivebeen stuck with a needle probably three times in my career. Its not fun; itsreally scary for that to happen.

Your chances of getting stuck are basically zero, points out AlanWeisshar, MD, of the Torrance Pediatrics Group in Torrance, Calif. We do have needles in the office that we use for TB skin tests, andinjections 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 fivetimes, probably once every four or five years. Its always when you have togive multiple injections, which is what a pediatrician has to do youregiving from two to four injections per kid, the kids moving, youre tryingto work fast to reduce the crying, and you have your standard of what you dowith your used needle when youre done, but your hand gets pushed or somethingmoves or you turn your head in the other direction. Its always when yourerushing. And now, I just dont have that risk, he explains.

The Biojector, he says, is a much nicer injection. Pain is very highlycorrelated to the material some vaccines are very painful and some vaccinesarent. But when you inject with a needle, you inject with one point and makea little ball. When you inject with a Bioject, it goes through the skin as astream but disperses, and the surface area is 15 to 20 times greater than theabsorptive surface area if you were injecting with a needle which means yourtake rate for vaccine is much higher, and thats why you cant use itwith Depo medication. If youre giving something like Depo-Provera, which isgiven for contraception every 90 days and you give it with a Biojector, theabsorption is so rapid and so complete that its gone in 60 days. Theabsorption of medication is much more efficient. The patient kindness is muchgreater, he adds.

Another product that has shown great potential is the Lasette from CellRobotics. The Lasette is a capillary blood sampling device that produces afingertip wound by laser ablation. United Blood Services (UBS), a national bloodbanking service, performed two pilot studies of the device and is now evaluatingit 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. Oncethe results were submitted to the corporate office, they made the decision thatthey didnt have enough information in order to go forward with everybodyusing 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, andone in Rapid City.

The two studies in Albuquerque evaluated donor comfort and the quality of thesamples. In the first pilot that we did with the blood donors, the majorityliked 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 thelaser; it smells like when you burn hair, which is offensive. The trick is tokeep the Lasette close enough long enough so the plume doesnt come out rightafter the Lasette sticks the finger.

The objection from the staff side [is related to] the way the Lasette ismade 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 CellRobotics to change the settings; the Lasette originally had settings from zeroto 10, and we were concerned about staff moving it up to the 10 mark, becausethat would be necessary very rarely. We asked them for settings of low andmedium, with no high, and they did that, she says.

The next study we did was for the quality of the sample, and how many moredonors would be allowed to donate using this. What we discovered was that asignificant number of donors would be allowed to donate using the Lasette whowouldnt have donated using the lancet. Also, if the donor doesnt pass thecopper sulfate test, then we do the spun hematocrit, and we found the quality ofthe sample was better, so more people passed the initial copper sulfate and didnthave to be spun, Waltman offers. Of course, the other thing is that thereare no sharps.

She adds, At the AABB (American Association of Blood Banks) conference inBaltimore this past year, Cell Robotics had a booth set up. I thought it wasreally interesting that people were standing in line to get a finger stuck. Andafter they got stuck, they were going back and getting friends of theirs to comeand get their fingers stuck. These are blood bankers, laboratory managers,administrators, anybody involved in the blood banking industry. I think evensome of the vendors were coming over and getting their fingers stuck.

Waltman concludes, I really think its a terrific device. Whether or notwe use that device, my thought is that the blood banking industry as a whole is going toward doing things that will make the donor morecomfortable in the process of donating blood anything that is financiallywithin reason and yields the results were looking for as far as more donorsbeing able to donate, and donor retention. The blood banking industry will begiving those things a hard look and incorporating the devices that help themmeet those ends.

Other facilities are adapting more conventional sharps safety devices; however, due to a lack of employee cooperation, these may not be assuccessful as hoped.

Prior to my arrival, the hospital had a committee called the sharps injuryprevention task force that was looking at the implementation of different safetydevices, says MaryAnn Gruden, CRNP, COHN-S/CM, coordinator, employee healthservices at the Western Pennsylvania Hospital in Pittsburgh. We switched overto some safety devices, and in the last year, weve actually restructured ourentire employee injury prevention program. Now that task force is part of thesubcommittee for our Work Safe program. In spite of all our safety sharps,we still have not seen a significant decline in our sharps injuries, sherelates.

This group used to meet quarterly; now they meet every month. Probably two years ago, we really started following up with our managers iftheres been an unsafe practice in an exposure, say, somebody didntactivate the safety feature, or there was improper disposal. When that occurs,we contact our education department representative and the nurse manager, andthen theres follow-up on that end.

The environment makes the risk much greater; the Western PennsylvaniaHospital is a teaching hospital with a large population of residents. Ourclinical nursing staff is the biggest group that experiences needlesticks; oursecond biggest group with needlesticks is residents, Gruden reports. Wevestruggled with what to do with them. In December 2004, we decided to involve thephysician program directors, so any time any kind of significant exposure occurswith one of the residents or medical students, their physician director gets amemo from our office. It says what happened, what they were doing, how they werecounseled, and we ask the physician director to get us feedback. Weve had apretty good response from that, surprisingly, because we didnt know what toexpect. They have given us feedback, and seem to be taking that seriously.

In the last six months, the sharps committee has taken to reviewing allsharps 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. Thefacility incorporates as many safety devices as possible BD SafetyGlidesyringes, Braun IV catheters, safety blood gas tips, safety butterflies, etc.The hospital is in the process of transitioning from a BD butterfly that has asheath on it to their push-button retractable phlebotomy butterfly. We have anumber of needlestick injuries related to trying to activate the safety featureon the butterfly, Gruden points out. Well also look at safety scalpelsin the operating room. Were also looking at BDs retractable syringes, theIntegra syringe, because we still have needlesticks related to IM(intramuscular) and subcutaneous injections. We used those retractable needleswhen we did the flu campaign in the fall. With the shortage of vaccine, we weretrying to stretch our vaccine, and with the Integra syringes, because theresless dead space, you can actually get more doses out of the vial. We want to atleast evaluate whether theyre appropriate, if not house-wide, but in certaindepartments. I feel like in the last year, weve done more with our sharpsprogram, and maybe a year from now, I can say weve really seen a significantdecline.