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By Jane Perry, MA
In the past six months, 11 states have passed needle safety laws: West Virginia, Minnesota, Maine, Georgia, and Iowa, all in April 2000; New Hampshire in May 2000; Alaska, Connecticut and Oklahoma in June 2000; Ohio in July 2000; and Massachusetts in August 2000. They join California, Tennessee, Maryland, Texas, and New Jersey on the list of states that have needle safety legislation on the books--almost one-third of states in the US. In addition, Maryland passed a second needle safety bill in February as a follow-up to its study bill from last year. Five states have bills pending, and others are planning to introduce bills in the next legislative session, including Nevada and Virginia. A number of state needle safety bills that were introduced during 1999 and early 2000 have died, but some of these may be reintroduced.
The needle safety laws passed thus far vary widely in their requirements and coverage. However, most of the bills include a "patient safety" exemption that California first developed: health care workers can choose not to use a safety device if they can show that doing so would jeopardize a patient's safety.
Â· Bill pending
Â· Law passed
Bill also passed in Alaska
The bills can be broadly grouped into three different categories. The first is "comprehensive" bills; included in this category are the bills passed by California and New Jersey, which are considered to be the most stringent thus far. New Jersey's bill, for example, requires all healthcare facilities, both public and private, to use needles and other sharp devices with integrated safety features by the end of 2000. Within the "comprehensive" category, however, the way the bills' requirements are carried out differ. Partly this has to do with whether a state has its own OSHA plan, as is the case with California, or is under federal OSHA, like New Jersey. California's law mandated that the state's bloodborne pathogens standard be amended to require the use of safety devices, a model followed by a number of other state-plan states. New Jersey, on the other hand, simply made the use of safety devices state law, although it also requires that the New Jersey Department of Health develop corresponding regulations.
Massachusetts' and Alaska's needle safety laws can also be placed in the "comprehensive" category.
Both Alaska's bill, SB 261, and Massachusetts' bill, HB 5394, contain four elements drawn from California's legislation:
(1) Sharps with "engineered sharps injury protection" must be included as engineering and work practice controls;
(2) written exposure control plans must include procedures for selecting sharps prevention technology;
(3) exposure control plans must be updated as necessary to reflect progress in implementing safety technology; and
(4) sharps injury logs must be maintained, with detailed information about exposure incidents.
Alaska's bill requires, like California's, that the state's bloodborne pathogens standard be amended to include these requirements. Massachusetts' bill mandates that the state department of health promulgate "regulations requiring the use, at all acute and non-acute hospitals" of safety devices.
The second category of state needlestick laws, study bills, includes those passed by Tennessee, Maryland, and, most recently, Iowa. These bills essentially authorize a study of the needle safety issue and appoint a committee for this task, requiring the committee to make recommendations for changes in state law or regulations within a certain time frame, usually a year.
Iowa's bill, SB 2302, follows this pattern: it calls for the state department of public health, in cooperation with the labor commission, to "conduct a study of state and federal laws and regulations relating to protection of persons who may be at risk of needlestick injuries in the course of employment ... [and] submit a report to the governor and general assembly by December 15, 2000, which shall include any recommendations for changes in state law or rules ... to improve protective measures relating to needlestick injuries."
Maine's bill, HB 1532, requires that the state conduct a survey of healthcare providers to determine the extent of safety device usage, and how they plan to comply with the revised compliance directive for federal OSHA's bloodborne pathogens standard. The results of the survey will be used to determine whether further legislation is needed.
A third category of state legislation is "public sector" bills. The laws passed in Texas, Georgia, New Hampshire, and Ohio fall under this category. For example, the Texas law mandates the implementation of safety devices, but covers only state and municipal health care facilities-approximately one-third of all health care facilities in Texas. Georgia's bill, HB 1448, requires that the state department of health adopt a bloodborne pathogens standard to cover public employees, and says that it must be "at least as prescriptive" as the federal OSHA standard. New Hampshire's law, HB 1244, calls for the commissioner of labor, in conjunction with the commissioner of health and human services, to adopt rules to protect healthcare workers in the public sector from occupational exposure to blood, and to establish an advisory council to advise the commissioners on the rules. Ohio's bill, SB 183, requires state health care facilities to include needleless systems, sharps with ESIP, and "other devices that comply with [OSHA's] bloodborne pathogens standard," as part of their engineering and work practice controls. Public employers also must develop and implement a written exposure control plan that is updated at least once a year to reflect progress in implementing safer devices.
Other states, including Pennsylvania, have similar "public sector" bills pending. What is the reason for this type of bill? In states that have federal OSHA plans--about half, including Texas, Georgia, Ohio, and Pennsylvania--federal OSHA has no authority to inspect or fine state and municipal healthcare facilities. This leaves a gap in OSHA coverage in federal-OSHA-plan states, and the public-sector needle safety bills fill that gap.
Minnesota's bill, SB 1202, does not quite fit into any of the above categories. Minnesota has a state OSHA plan, and state plans are required to have regulations that are "at least as" effective as federal OSHA regulations. Minnesota's bill appears to update the state's bloodborne pathogens standard to reflect federal OSHA's revised compliance directive. It says that written exposure control plans must "reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens" and must "document consideration and implementation of ... effective engineering controls ... designed to eliminate or minimize exposure." Safety committees must make recommendations for the use of effective engineering controls, and sharps injury logs must be kept with detailed exposure information.
Several state needle safety bills present problems or raise questions. Oklahoma's bill, HB 2139, requires that a needlestick injury prevention committee, appointed by the state, submit proposed rules for preventing needlestick injuries and implementing devices with ESIP, and mandates that "sharps prevention technology be included as engineering or work practice controls in high exposure areas." However, the bill states that permanent rules don't have to be submitted until March 2004--almost four years from now-although it does say that emergency rules have to be in place by that date. The bill also contains a clause stating that if the needlestick prevention committee "determines that there is a sufficient use of sharps prevention technology in the state, prior to the promulgation of rules... the Committee shall recommend... that the proposed rules not be promulgated" [emphasis added]. It is unclear how "sufficient use" will be defined. Given the long lead time and qualifying language in this bill, it appears that it will have little or no immediate impact on the safety of frontline healthcare workers.
The synopsis of West Virginia's law, HB 4298, indicates that its main purpose is to establish an advisory committee to recommend needle safety rules to the department of health. However, in the bill itself there is language stating that a facility must, as part of its injury prevention program, use "hollow-bore needle devices or other technology known to minimize the risk of needlestick injury to health care workers." It is unclear what the intent is behind this broader, more comprehensive language, or how it will be applied.
Connecticut's HB 5911, an expenditure bill for the Department of Public Health, includes a brief passage (section 6) on needlestick prevention. It states, "Each health care facility or institution licensed by the Department of Public Health... if advised by the federal Occupational Safety and Health Administration, and each healthcare facility or institution that employs state employees, shall use only injectable equipment having self-contained secondary precautionary type sheathing devices or alternate devices designed to prevent accidental needlestick injuries" [emphasis added]. Since federal OSHA has, in the revised compliance directive, said that engineering controls must include devices with ESIP, this passage would appear to cover both public and private facilities. But what categories of sharp devices does it cover? Is it meant to cover only injection equipment, or all needle devices? Furthermore, what "alternate devices designed to prevent needlesticks" would qualify under the law? Enforceable definitions are needed.
While there is a great deal of variation in the scope and strength of state bills on needle safety, it is encouraging that so many states have taken action and moved ahead so quickly. The variability in state laws, however, also underscores the need for federal legislation in order to provide consistent and comprehensive national standards and avoid a patchwork of requirements from state to state. Further, despite the progress, more than half the states have no needlestick prevention bill, either passed or pending. Congressman Pete Stark (D-CA) and Congresswoman Marge Roukema (R-NJ) introduced a federal bill last year-the Health Care Worker Needlestick Prevention Act (HR 1899)-which so far has 186 co-sponsors. Similar to California's legislation, the Stark bill would mandate that federal OSHA's bloodborne pathogens standard be amended to require that employers utilize needleless systems and sharps with ESIP. The bill is currently before the House Committee on Education and the Workforce, which has jurisdiction over OSHA. While such a bill could bring uniformity to the legal patchwork, it is unlikely to pass this year. However, Rep. Stark says that "chances are good" that the bill will pass next year, given that "Republicans have finally discovered" the needle safety issue.
Jane L. Perry, MA, is the director of communications, managing editor of Advances in Exposure Prevention, University of Virginia, Charlottesville, Va.
This information was originally published in Advances in Exposure Prevention, a publication of the International Health Care Worker Safety Center at the University of Virginia. It has been updated and is reprinted in Infection Control Today®.
Maryland's HB 287 required that a study group on needlestick injuries be formed for the purpose of producing a report and recommendations by the end of 1999. The study group distributed a survey in October 1999 to 202 licensed healthcare facilities in Maryland addressing the utilization of ESIP technology and whether or not usage was mandatory. Ninety-one facilities completed the survey (45% response rate). The data were compiled and analyzed by the Center for Epidemiology and Health Services Research at the Maryland AIDS Administration. Key findings of the study group's report, completed in December 1999, include the following: