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By Kris Ellis
The International Healthcare Worker Safety Center at theUniversity of Virginia recently reported that data collected from 48 U.S.healthcare facilities in 2003 via the EPINet surveillance program showed thatparticipating hospitals experienced 23.87 percutaneous injuries (PIs) per 100occupied beds.1 The report notes that great variation existed between thefacilities involved from a zero PI rate at six facilities to a rate of morethan 50 per 100 beds at two facilities. Statistics such as these underscore thefact that sharps safety is still a significant issue in some areas.
While efforts on the part of clinicians,educators, manufacturers, and legislators to wipe out sharps injuries haveundoubtedly made hospitals safer places, for many, there is much work yet to bedone.
Step one is to get the right devices in place, says Gina Pugliese, RN,MS, vice president, Safety Institute at Premier, Inc. To do that you needinput from the workers who are going to be using those devices so they canchoose devices that they like. If you get them involved in the process, which iswhat the Occupational Safety and Health Administration (OSHA) requirement is,youll get buy-in from the front lines. Thats really the key.
If your front-line workers do not like what theyre using, you have aproblem, Pugliese continues. If you choose a product and your front-lineworkers find that they dont like it, you need to have another evaluation andfind something they do like, which is why you have an annual review, because noteverything will necessarily work after you implement it it might be toocomplicated, it might not work in the kind of disposal units you have, peopleshand size might be an issue, the design might have changed slightly from theoriginal, the safety feature might not be reliable, it doesnt fit with otherdevices easily, for example there are all kinds of potential issues. Youhave to have an ongoing review of what youre doing.
Pugliese explains that only front-line workers can evaluate device nuancesthat must be accounted for. There are so many different factors you canconsider when you choose a device and thats why theres such a variation inselection the size of the hand, whether theyre right-handed orleft-handed, whether theres an audible change like a click or sound, or acolor change, how complicated they are to use, etc.
Incorporating safety devices wherever possible is a vital step for allfacilities, but it cannot guarantee an injury-free environment. Data from the International Healthcare Worker Safety Center report showedthat of the 1,708 total injuries described, 340 occurred when a safety featurewas not activated.2 If you only have sharps safety devices, are they using them correctly? Pugliese questions. In other words, are they activating the safety feature, or are theythrowing them in the sharps safety disposal unit without activating them? A lotof the needlesticks are happening because the devices are not activated. Workers need to be aware of the risks when they do not activate the safetymechanism. Some workers choose safety devices that activate in a passive manner, thatis, the safety mechanism automatically works as part of the procedure, such as aretractable needlesyringe. With passive activation of the safety feature, you do not have to rely onworker compliance. However, there is a range of technology out there to choosefrom, both active and passive, and the final decision relies on what ispreferred by the worker.
Very frequently, and most unfortunately,a good number of injuries occur with the use of safety devices, becausehealthcare workers didnt activate the device, says Rita McCormick, RN, CIC, infection control practitioner at University of Wisconsin Hospital andClinics. That really needs to be underscored, because facilities clearly haverecognized that theyre obligated to provide safety for the worker andeverything is a two-way street workers have obligations, and employees haveobligations. In most places, employers have embraced their obligation to providesafety for their workers quite well. It boggles my mind that people simplydecide to not use something that was purchased at sometimes as much as threetimes the cost, and they get stuck with it.
Pugliese also points out that bloodborne pathogens can affect patients aswell as workers. If you choose a sharps safety device to use in the OR, youre protectingyourself as a worker from the blood of the patient, and if you happen to stickyourself during surgery and a drop of blood goes into the patient, then youveexposed the patient to your blood, so in the OR, sharps safety is for both thepatient and the worker.
The Educational Challenge
The process of educating and informing healthcare workers about theimportance of preventing bloodborne pathogen exposure is a continual effort formany infection control practitioners. If you really look at the principles ofadult education, people want information when its relevant to them, so youlook for teaching moments, McCormick explains.
There is no better teaching moment than when the person is being worked upfollowing a needlestick injury. From my perspective, although some peopledispute whether there is time for this to always be done, I think itsworthwhile for the employee health people who do the post-exposure follow-up totry and determine exactly what happened when this occurred, and if they wereaware of how the device works, because sometimes they might have been taught oneparticular device, know it backwards and forwards, and they come to a newhospital and that device is no longer there and they need to learn new devicesand so on. Is education adequate at that time?
Devoting sufficient time and resources for effective training and educationis a necessity for new devices. Not all devices are intuitive, McCormick cautions. Its hard to get everybody on every shift as well.As more and more safety devices come into the workplace, youll see moreinjuries that occur even when a safety device is in use thats the natureof the beast.
Then you have to examine, Why are we seeing injuries with this device?If theyre not activating it, thats pretty self-explanatory, but if theyindicate on the incident report that they had trouble activating it, or theythought it was activated when it actually wasnt, then youve got to go backand see if theres a better device on the market.
The method by which a device is activated can become an issue as well. Mostof the time when the manufacturer made a safety device, they had in mind apreferred way of activating it, McCormick continues. When people makemodifications to that, they get into trouble. For instance, at her facility a butterfly needle is being phased out andreplaced. It was designed by the company to be changed using a one-handedmethod, but that one-handed method is difficult. Even if they understand it andtry to do it, its not working very well and weve had injuries because ofit, so were going to a new one.
This example illustrates that importance of clinician input once again. Youcant underscore enough the need to get front-line workers involved in theevaluation of the device, because thats where the action is, McCormick continues. Sometimes when the rep comes and shows it to themanager, who doesnt use it very much, it looks good, but when you put it intouse, issues may arise.
McCormick again emphasizes that healthcareworkers must take responsibility for their actions. It is just very importantfor workers to realize that they have obligations in this as well, and one ofthem is to activate the devices, she says. To look into needle boxes andfind unactivated equipment is really sad, because the facility spent a lot ofmoney to buy that.
Given that the message about bloodborne pathogens has been repeated manytimes over the years, a fresh means of reinforcing its importance may be useful.Any time you can present local data, your own data within your own hospital,and you can identify according to the circumstances when the injury occurred,such as failure to activate, you can deem those preventable injuries,McCormick says. To provide people with data that says, In the last year,28 percent of our injuries were deemed preventable because people didntactivate the device, youd better listen up on this one.
While national data, articles, and similar information is vital, first-handexamples are impossible to ignore. Nothing works better, although Im notadvocating it, than a seroconversion, McCormick continues. Word travels fast. There have been articles writtenthat described how, once there was a conversion, then administration got onboard with the need for more emphasis and things were made available, etc. Ifthat happens, very unfortunately, then use it for a teaching moment. Thats apossibility, but you really hope it never occurs.
McCormick also points out that in some instances, clinicians do somethingcareless or out of the ordinary that leads to a needlestick, and thus may behesitant to report it. There should never be a punishment because you failedto follow a technique, and that needs to be a very positive thing to make surethat it doesnt happen again, she says. You need to go over the detailsand see if it was a procedural issue or an equipment issue.
In addition to protecting themselves and their patients, healthcare workerswho are conscientious about sharps safety also contribute to the protection ofother facility employees. We occasionally still have a custodian who gets stuck because someone lefta needle on the floor of the emergency room, McCormick says. We have anobligation to protect ourselves, be we also have an obligation to protect ourfellow workers. You would never want to have that on your mind, that what youdid possibly resulted in a seroconversion. Every person who uses a sharp isobligated to take care of it to final disposal. It doesnt matter if itsthe chief of surgery he or she has the same obligation. That needs to be reinforced by upper-level administration.
Clinicians are aided in their quest to create a safer environment by theincreasingly large number of safety devices on the market. It always amazesme that when new issues come up in healthcare that manufacturers step up to theplate, says McCormick. For needlestick issues, companies are now becomingused to providing a place to stick that sharp tip until you can dispose of itwhere it belongs.
Theres so much new technology and more is coming out all of the time,Pugliese says. She also acknowledges that for improvement does exist in this sensenonetheless. There are a couple of areas in which there probably need to bemore devices. More products for the operating room, probably, especially safetyspecialty blades. Surgeons seem to be resisting using safety blades, so therereally needs to be an evaluation of whats out there and some additionalsafety blades perhaps. The other thing places where there might be someopportunities for creating more sharps safety devices would be introducerneedles, spinal and epidural needles, arterial line needles, biopsy needles, things like that.
In the 2003 publication Exposure to Blood:What Healthcare Personnel Need to Know, the Centers for Disease Control andPrevention (CDC) acknowledges that healthcare personnel are at risk foroccupational exposure to bloodborne pathogens, including hepatitis B virus(HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).Exposures occur through needlesticks or cuts from other sharp instrumentscontaminated with an infected patients blood or through contact of the eye,nose, mouth, or skin with a patients blood. Important factors that influencethe overall risk for occupational exposures to bloodborne pathogens include thenumber of infected individuals in the patient population and the type and numberof blood contacts. Most exposures do not result in infection. Following a specific exposure, therisk of infection may vary with factors, including:
Your employer should have in place asystem for reporting exposures in order to quickly evaluate the risk ofinfection, inform you about treatments available to help prevent infection,monitor you for side effects of treatments, and determine if infection occurs.This may involve testing your blood and that of the source patient and offeringappropriate post-exposure treatment.
How can occupational exposures be prevented?
Many needlesticks and other cuts can be prevented by using safer techniques(for example, not recapping needles by hand), disposing of used needles inappropriate sharps disposal containers, and using medical devices with safetyfeatures designed to prevent injuries. Using appropriate barriers such asgloves, eye and face protection, or gowns when contact with blood is expectedcan prevent many exposures to the eyes, nose, mouth, or skin.
What should I do if I am exposed to the blood of a patient?
1. Immediately following an exposure to blood:
No scientific evidence shows thatusing antiseptics or squeezing the wound will reduce the risk of transmission ofa bloodborne pathogen. Using a caustic agent such as bleach is not recommended.
2. Report the exposure to the department (e.g., occupational health,infection control) responsible for managing exposures. Prompt reporting isessential because, in some cases, post-exposure treatment may be recommended andit should be started as soon as possible. Discuss the possible risks ofacquiring HBV, HCV, and HIV and the need for post-exposure treatment with theprovider managing your exposure. You should have already received hepatitis Bvaccine, which is extremely safe and effective in preventing HBV infection.
What is the risk of infection after an occupational exposure?
1. HBV Healthcare personnel who have received hepatitis B vaccine anddeveloped immunity to the virus are at virtually no risk for infection.
For a susceptible person, the risk from a single needlestick or cut exposureto HBV-infected blood ranges from 6 percent to 30 percent and depends on thehepatitis B e antigen (HBeAg) status of the source individual.
Hepatitis B surface antigen (HBsAg)-positive individuals who are HBeAgpositive have more virus in their blood and are more likely to transmit HBV thanthose who are HBeAg negative. While there is a risk for HBV infection fromexposures of mucous membranes or nonintact skin, there is no known risk for HBVinfection from exposure to intact skin.
2. HCV The average risk for infection after a needlestick or cut exposureto HCV-infected blood is approximately 1.8 percent. The risk following a bloodexposure to the eye, nose, or mouth is unknown, but is believed to be verysmall; however, HCV infection from blood splash to the eye has been reported.There also has been a report of HCV transmission that may have resulted fromexposure to nonintact skin, but no known risk from exposure to intact skin.
3. HIV The average risk of HIV infection after a needlestick or cutexposure to HlV-infected blood is 0.3 percent (i.e., three-tenths of onepercent, or about 1 in 300). Stated another way, 99.7 percent of needlestick/cutexposures do not lead to infection. The risk after exposure of the eye, nose, ormouth to HIV-infected blood is estimated to be, on average, 0.1 percent (1 in1,000). The risk after exposure of non-intact skin to HlV-infected blood isestimated to be less than 0.1 percent. A small amount of blood on intact skinprobably poses no risk at all. There have been no documented cases of HIVtransmission due to an exposure involving a small amount of blood on intact skin(a few drops of blood on skin for a short period of time).
What follow-up should be done after an exposure?
1. HBV Because post-exposure treatment is highly effective in preventingHBV infection, CDC does not recommend routine follow-up after treatment.However, any symptoms suggesting hepatitis (e.g., yellow eyes or skin, loss ofappetite, nausea, vomiting, fever, stomach or joint pain, extreme tiredness)should be reported to your healthcare provider. If you receive hepatitis B vaccine, you should be tested 1-2 months aftercompleting the vaccine series to determine if you have responded to the vaccineand are protected against HBV infection.
2. HCV You should be tested for HCV antibody and liver enzyme levels(alanine aminotransferase or ALT) as soon as possible after the exposure(baseline) and at four to six months after the exposure. To check for infectionearlier, you can be tested for the virus (HCV RNA) four to six weeks after theexposure. Report any symptoms suggesting hepatitis to your healthcare provider.
3. HIV You should be tested for HIV antibody as soon as possible afterexposure (baseline) and periodically for at least six months after the exposure(e.g., at six weeks, 12 weeks, and six months). If you take antiviral drugs forpost-exposure treatment, you should be checked for drug toxicity by having acomplete blood count and kidney and liver function tests just before startingtreatment and two weeks after starting treatment.
You should report any sudden or severe flu-like illness that occurs duringthe follow-up period, especially if it involves fever, rash, muscle aches,tiredness, malaise, or swollen glands. Any of these may suggest HIV infection,drug reaction, or other medical conditions. You should contact the healthcareprovider managing your exposure if you have any questions or problems during the follow-up period.