Needlesticks and sharps injuries continue to be a significant occupational hazard. Healthcare workers (HCWs) sustain between 600,000 and 1 million injuries from conventional needles and sharps annually. In 2000, then-President Bill Clinton signed into law the Needlestick Safety and Prevention Act, whose requirements included documented exposure control plans and logs in healthcare facilities, use of safety-engineered sharp devices and needleless systems, and the solicitation of input from frontline HCWs when identifying, evaluating, and selecting safety-engineered sharp devices.
Six years later, HCWs are asking themselves how much progress has been made in preventing needlesticks and other sharps injuries. To this end, the Inviro Initiative: Evaluating the State of Needlestick Prevention was held during the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC). Inviro Medical developed, coordinated, and sponsored this thought-leader roundtable event, held in mid-June, in conjunction with ICT magazine as the programs moderator and exclusive media sponsor. Participants were Lisa Black, PhD(c), MS, RN, assistant professor at the University of Nevada Orvis School of Nursing; Boston College doctoral student Karen Daley, PhD(c), MS, MPH, RN; Barbara DeBaun, RN, MSN, CIC, director of patient safety and infection control at California Pacific Medical Center; June M. Fisher, MD, project director of the Training for Development of Innovative Control Technologies Project (TDICT); Lynn Hadaway, MEd, RNC, CRNI, executive director of National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI);
Nancy L. Hughes, RN, MHA, director of the Center for Occupational and Environmental Health for the American Nurses Association (ANA); Angela K. Laramie, MPH, of the Sharps Injury Surveillance and Prevention Project and the Occupational Health Surveillance Program of the Massachusetts Department of Public Health; and Ron Stoker, executive director of the International Sharps Injury Prevention Society (ISIPS). The event was moderated by Bill Eikost, publisher of ICT; program hosts were Gareth Clarke, CEO of Inviro Medical, and Karen Dunlap, senior vice president of sales and marketing for Inviro Medical.
The discussion began with a review of where the industry stands in terms of awareness of the magnitude of sharps injuries among HCWs. Fisher advocated for a renewed campaign, remarking, (Sharps injury prevention) is not on the political agenda. If were going to get anywhere, it has to get back on the national political agenda. The group debated whether or not the needlestick legislation had a lasting impact. I think weve penetrated the market to a greater degree with safety-engineered devices, Daley said. It doesnt mean weve penetrated the market with the best devices. It doesnt even mean weve been successful with those devices in terms of preventing injuries. There is data suggesting anecdotally that hospitals have reduced injuries over time, but we dont know if we have educated people. I think in certain places, after five years, the culture has changed, and that has been happening probably in bigger cities and hospitals where cost is not such a major issue in terms of complying with the new federal regulations. But I havent seen much change in smaller community hospitals and clinics. On a personal level, I get my blood drawn every three months. I went in and the nurse was using a butterfly. I asked her how she liked it and she said, I love it. Five years ago I could have asked a nurse how she liked that safety device and she would have said, I hate it. But enough time has gone by where youre seeing some of these changes mandated by the legislation becoming normal within the healthcare culture. That doesnt mean that some of the reporting is getting any better but I think thats the best that can be said.
Laramie added, I think some of the things that have contributed to the success of minimizing and reducing the number of needlestick injuries are that many of the things that were implicit in the original bloodborne pathogen standard were made explicit and there are a lot of new things that we have to do. They arent really new; they just werent spelled out clearly.
Roundtable participants discussed how to identify and remove barriers to implementation of safety devices; many said that end users of safety-engineered devices must be included in any discussions about breaking down these barriers. Fisher commented, We need user-based designs. Many modifications are being made by those who have no idea what is going on. As long as the HCW is not involved, you are not going to get the correct design of devices. You can get physicians on board if you involve them. Youre not going to get them on board if you bring them in and tell them, This is what we bought, and you use it. That approach is simply not going to work.
Daley noted, Partnerships must be built between the institutional providers and the manufacturers, and the manufacturers have to be driven by the users through partnerships with these institutions. Davis concurred, adding, I look at Massachusetts where, through partnerships, weve been able to engage in 100 percent reporting, and thats huge. At some point you also take it to another level, where you say, Not only can we help you build systems that will reduce injuries, but we would like to involve you in designing projects that will meet your needs. I think industry must approach the healthcare institution and the institution has to engage the HCWs who use the products. Its not simply, Heres the product, try it and tell us how you like it. To which Fisher added, Most manufacturers will design something in isolation. Then theyll go to HCWs and say, Evaluate this and tell us what you think. By that time, theyre so far into the design and invested in the product, you cant back up at that point. Id like to see a panel brought together to determine the 10 critical issues we need to know about a device and we put it out there. Lets pool the data to know whether the device is good or not.
Laramie discussed the success that Massachusetts has had in achieving sharps-safety compliance: Were rather proud of the fact that we have 100 percent reporting by the approximately 100 hospitals in the state which were tracking of injuries and illnesses. Having a standard minimum data set to collect and provide has made things easier for them. We decided that we would design our surveillance system so that they could comply with federal as well as state regulations. Were trying to convince hospitals they need to use the data in making decisions about which devices they purchase and what areas they focus on in terms of prevention.
The group turned its attention to the problem of underreporting. Laramie noted, One of the things that we have found in Massachusetts is that the number of injuries reported every year has remained relatively stable; it has decreased by no more than 100 injuries per year, which is roughly one injury per hospital. My hope, although I cant substantiate it, is that theres more reporting going on, prevention strategies are making an impact, and were changing cultures within hospitals and encouraging people to report. What weve heard in several hospitals is that in the OR, underreporting is much more significant than in other settings.
Daley suggested that one important related challenge is getting nurses, especially those in the busy OR environment, to report sharps-related injuries: Nurses say they are too busy. They probably feel too inundated to leave to report the injury. But they are also impacted by a system not streamlined enough to accommodate them in a reasonable amount of time. Its not simply the follow-up, its the post-exposure kit.
In the facility where my exposure and infection occurred, we brought the occupational health people to the unit; if that phone call is made, triage is done over the phone, and post-exposure prophylaxis is indicated, it is brought to them. That kind of response system has been very effective. The other innovation has been in terms of technology; what has helped drive better reporting is the rapid HIV test.
Are sharps injuries simply unpreventable? The consensus, as expressed by one participant is, Well, there are factors that contribute to the system, but until we can effectively remove the hazard its going to happen. Were human and that human factor is really a big thing. De Baun noted, As long as there is a sharp needle on the fi eld, its not a systems fi x; its going to be human error, and theyre just sharp things that are going to result in a stick. Black added, I think though, that the issue of talking about human behavior and talking about cases where you need to eliminate the needle, there are cases where the needle has to be there. For as long though a device requires nurses to activate something, move something, shield something, were not going to be there in terms of avoiding injuries. Fisher commented, The acronym we have been using for a long time is PEST: Passive, Easy, Simple, Throughout. That is what we want in a device. It should be passive, it should be easy, it should be simple, and it should last throughout. When we have devices that meet that criteria things will change.
Roundtable participants debated about whether or not HCWs are ambivalent about accepting responsibility for their own safety. Laramie remarked, Ive used the PEST acronym when I speak about sharps safety because its simple and nurses get it. I also have to say that human behavior interferes with the process of safety. When people say that they dont activate the safety mechanism because theyre too busy, I think it means that they dont know how to because they didnt have enough knowledge or training to do so. If they havent had adequate training in activating a non-passive device, theyre probably not going to activate it. We used to survey the sharps-disposal boxes to see how many safety devices had been activated.
We used that as kind of a barometer to tell how well we were doing in terms of training. One of the aspects of human behavior is attitude, with HCWs taking injuries and other occupational hazards in stride. Daley said, Nurses typically accept that there is so much risk in their profession, they think that needlesticks go with the territory. Another participant concurred: Its the cost of doing business for nurses. I can speak to a group of 100 nurses to 500 nurses, and when I ask how many of them have been stuck by a needle, at least two-thirds raise their hands. When I ask how many have been stuck and not reported it, probably half of those two-thirds raise their hands its universal wherever I go.
Talk soon turned to innovations on the market. Said Stoker, Some of the interesting things Ive seen in the last two years are retrofitting of products. We see less of that going on and more new products being made. My grandmother used to have a saying that its better to prepare and prevent than it is to repair and repent. I think thats really the case. If we design and plan something, its better to do it that way then going back and fixing something. Also, were all familiar with the fact that for years we would see people separate the needle from the holder and drop the needle into the sharps container and put one back on the try and keep reusing it. People would pick them up and look at them and say, 'Thats not my blood.' I think thats been a great improvement. Black asserted that much of the conversation about sharps injuries has moved away from the original intent: I think a lot of us have talked about OSHA (the Occupational Health and Safety Administration) and JCAHO (the Joint Commission on Accreditation of Healthcare Organizations) and NIOSH (the National Institute for Occupational Safety and Health) and what they are or are not doing, but really what we are doing is yielding to pressure from manufacturers who have moved us away from the original intent of the imperatives from OSHA and the CDC (the Centers for Disease Control and Prevention) to make these devices more than just a traditional device with a new doodad attached to them. Some manufacturers have moved the focus from where it needs to be, which is to make devices safer. If you put a little doodad on a device that a nurse has to push, havent we moved away from the original idea of not making the user have to activate something to make it safer? Karen was talking about looking into sharps-disposal boxes; she had a student who opened a few of these boxes very carefully, looking for devices that had been activated. What she found was that just 17 percent of these devices had been activated. The student went around and asked everyone why they didnt activate the safety mechanism and she was told that either they dont know how, they didnt know they were supposed to, or it takes up more room in a sharps disposal box and the box fi lls up faster, or the little doodad makes the needle stick out of the sharps-disposal box. Again, its the doodad, added Black, referring to retrofitted devices.
Laramie remarked, I have to say though, given human nature, the gold standard is passive devices, but the cost is a concern. There was talk that the industry expected use to increase once passive devices became mainstream, and that we would see the cost of these devices come down. I dont know where that issue stands now, but absent being able to control the quality and consistency of training in every facility in this country, maybe part of the push has to be toward passive devices. We need to evaluate whether they are passive and they do stay activated throughout the process. They must be easy to activate, however. I tell people if it takes three hours to learn how to use a syringe, you dont want to be using that syringe. The reality is that industry must move toward simplicity and ease of use.
When asked for a sharps-safety related wish list, roundtable participants eagerly shared ideas and suggestions. Fisher said, I would like safety innovation geared toward high-risk exposures; fewer injection needles and more blood-draw IV start needles. Thats where I think the emphasis needs to be. Second, I am very concerned about the fact that a lot of the technology to prevent needlesticks is great for HCWs but its causing a lot of problems in our patients. We are seeing an unbelievably high number of bloodstream infections in our patients because of the needlefree devices.
Hadaway remarked, I would like to see industry marry the concept of primary and secondary prevention. You cannot have a comprehensive program by using sharps-engineered devices only. You have to look at all the new technologies coming on the market as well as other strategies that remove needles totally and completely. I also think that device manufacturers do a good job of training on their particular product, but not all manufacturers invest in continuing education as a marketing tool. If you educate the workers, the people at the bedside, they make better decisions, better choices. Its not just about training but that whole education piece as well.
Davis noted the need to collect data on an absolute regular basis to benchmark, and commented, We somehow need to begin the process of annual online surveys to look at three or four outcomes in terms of involvement in training, involvement in evaluation of the selection of devices, the quality of devices, three or four med tracks. Measure the same thing every year, including reporting and underreporting. That way, we could begin to benchmark some of the quality indicators. One participant said that there is a lack of data in terms of which specific mechanisms are being used, and which devices are involved in sharps injuries. The participant expressed concern over the content of packs, and Fisher commented, I see kits and trays with traditional devices and we have been cited for it. We have had screaming sessions with some of the manufacturers, and what provoked me is that the kits and trays were advertised as acceptable by OSHA. But safety devices were not included in them. The manufacturers said theres no market for them. Said Laramie, Ive been to a couple of the kit manufacturers and their response to us, as far as initiating a safety kit or tray is concerned, was that they will only put it in if its requested by the end user. If the end user doesnt say to them I want the Inviro snap safety syringe, or something similar, they dont put it in. Fisher replied, Kits and trays are easily done. Im saying bring the manufacturers, users, and regulators together. There should be some consensus about the contents of kits and trays. Laramie noted, If a facility uses one type of product and another facility uses another type of syringe and they want to customize that kit, then it makes sense to only do what the facility is asking.
Hughes remarked, What Id like to see, and what Im working toward at the ANA, is to teach people to be proactive in their own safety. I think people need to be taught this. People need to go into the workplace with the expectation that there are safety devices. They need to be proactive in their safety committees, including taking a hard look at the selection of products, the design of products, and ways they can advocate sharps safety.
Fisher said she is advocating greater investment in innovation: We need to push people for innovative devices. There ought to be an award for an innovative procedure. We need to look at other ways to cut down on the use of needles, to analyze the way we are doing things, and to determine how to do them differently. Its not always about technology. Id like to have a comprehensive approach, even if we have to mandate that there be more staffing and more education and training. Id like people to have power and a voice about the issue. Id like to see a group of people brought together with national leaders to develop better standards. We need to look to strategies that will mobilize our proactive power instead of just reacting to devices that are no good. I really think change has to come through organized groups, and I think its going to have to come through nursing.
The bottom line is that there are still too many HCWs who do not know enough about the activation of safety devices. Laramie emphasized, Its becoming clear to me that the negative comments about safety devices are coming from people who dont know how to use them. Theyre not being trained in how to use them. Our own state epidemiologist said that he didnt know how to use the device because nobody explained to him that you have to perform the retraction a certain way. Theres a lot of room for improvement and theres a learning curve. I think hospitals have done a better job in involving workers in the selection of devices, but I think there must be better training offered by manufacturers.
Fisher remarked, I came up with 13 Cs for preventing occupational hazards. We need a caring environment. Another one is commitment; we need to have commitment from the top down. Another is comprehensive; you must have a comprehensive program and it needs to be continuous. It has to be consistent and continuous and we need champions. You need a culture of safety and communication and a clinically based program. The last thing is we should be promoting committee involvement.Â