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By Kris Ellis
Infection control practitioners (ICPs)are intimately aware of the potential danger to healthcare workers (HCWs) posedby bloodborne pathogens via accidental needlestick injuries. While the exact prevalence of such injuries is unknown, theNational Institute for Occupational Safety and Health (NIOSH) estimates put thenumber somewhere between 600,000 and 800,000 per year.1 Furthermore, about half of these are not reported. Other studies actively seeking to monitor the rateof needlestick injuries have reported as many as 839 injuries per 1,000 HCWs.2 The cost that facilities must absorb to manage these injuries is significant, and can become catastrophic ifthe injury results in the acquisition of an infectious disease.
It is widely recognized that the use of sharps safety devicesand related products and technologies can be instrumental in helping facilitiesto protect their HCWs and patients. The Occupational Safety and HealthAdministration (OSHA) has enforced the use of sharps safety devices by employerssince 1999, and recommends that front-line workers be involved in the selectionand evaluation of safety devices.3 NIOSH recommends that employers of HCWseliminate the use of needles where safe and effective alternatives areavailable, and implement the use of devices with safety features and evaluatetheir use to determine which are most effective and acceptable.
As technology continues to advance and an increasing number ofclasses and models of safety devices are made available, HCWs, and ICPs inparticular, are faced with the continuing challenge of seeking out the bestsafety solutions, both in terms of cost and efficacy. Although potentially painstaking, this effort can have asignificant impact on a facilitys overall level of safety and on quality ofcare. Continual education on and practice of proper techniques anddevice usage are also integral parts of any safety effort.
Regardless ofwhat sharps system you have in your institution, you should continue to look(for a better alternative), says Providence Budet, RN, MPH, CIC, director ofinfection control at Bronxville, N.Y.- based Lawrence Hospital Center. Nomatter whats in place, I will always look to see if theres room forimprovement, and of course there generally is, because the whole impetus of asharps safety program should be to have a device that employs a one-handedtechnique that can be implemented without bringing your second hand into it sothat you diminish the potential for a needlestick.
This attitude led Budet to initiate the implementation ofretractable needle syringes at a large metropolitan facility in which shepreviously worked. After seeing the product showcased, Budet introduced it tothe new products committee, where it was approved. The syringes were thenbrought in for trial.
Then, based on feedback from the nurses, because theyrethe ones who use the needles most frequently, the determination was made tobring it into the institution, Budet continues. And of course part of thatis based on the cost involved, and thats one thing that always makes it moredifficult to bring in a new product the new product will usually be morethan the previous one.
After some initial concern on the part of a few nurses abouthow patients would react to the new devices, a comfort level was soonestablished. Its like everything else everybody has a learning curveand everybody needs to have a chance to feel good about it, Budet says. Thisis a product that you can really feel comfortable with, because every time youdepress that needle, it works. I cant begin to tell you how many shots Ivegiven, and I have not had one problem.
Youre not supposed to pull it out of the arm youjust depress it and you make the needle fly into the barrel without removing itfrom the arm, so they thought the patients would be uncomfortable, Budetexplains. Patients would ask, Is it out yet? and wed say, Itsalready over. Its in and out, and its so smooth.
In terms of impact on needlestick safety, the product switch was a resounding success. Its helped safety because, even if you wanted to recap, theres no needle there its gone, Budetpoints out. And people generally dont recap, so its not a problembecause theres no needle there. So that walk from the site of use to thesharps container is a safe walk it is no longer a potential hazard or anaccident waiting to happen.
As a longtime proponentof sharps safety, Connie Steed, RN, BSN, CIC, director of infection control atGreenville, S.C.-based Greenville Hospital System University Medical Center, haslearned many valuable lessons in identifying and correcting safety issues. Wehave a pretty refined process, she says. We maintain data on allhealthcare worker exposures in a database called EPINET, which was originated byDr. Janine Jagger at the University of Virginia. We analyze thatdata on a regular basis and the data breaks down who gets exposed, how they getexposed, when they get exposed, and what they get exposed to. What you can do is analyze where your injuries are occurringand where you need to concentrate your focus.
We have safety devices, but there are some issues with whypeople pick the ones they use and do they activate them correctly, Steed continues. Those decisions as to what we focus on arebased on data, and we analyze it, its reported out, its communicated back,and we base risk-reduction efforts on that data and we prioritize based on thatdata. Thats how our program is set up, and every year we develop objectives;targeted or focused objectives on what were going to focus on that year.
Steed explains that phlebotomy has been an area of concern inher facility for several years. We continue to have concerns about that areabecause those are high-risk exposures theyre hollow bore, so if I had myway we wouldnt have any, and thats not completely possible, but Imreally concerned about those, she says. Analysis of the situation indicatedto Steed that injuries were more prevalent with the use of certain devices. Shealso noted that established processes and procedures were not always beingadhered to.
Part of the challenge in addressing the issue revolved aroundthe number and variety of hospital employees who draw blood, according to Steed.A lot of hospitals have phlebotomists that draw blood all day long and thatsall they do, but at our hospital, nurses and phlebotomists can draw blood, so wedont have as much control, she says. Instead of having 80 people whodraw blood, we have 3,000. You can imagine if you have that many people doing theprocedure it would be harder to control the process.
First, a team was put together to perform a root-causeanalysis. Once the root cause of the exposures was identified, flowcharts werecreated for the procedures. What we found out was that some of it could beeliminated by using safety devices, but some of it was behaviors, like how theblood is transferred, Steed says. We identified opportunities in theprocess by flowcharting and then we looked for safety devices or changes inprocedure that would eliminate the risk.
Several safety devices were implemented for each type ofphlebotomy product that was being used, and education measures were improved.Steed notes that these efforts paid off in the end by decreasing needlesticks.We had to train folks and develop competency methods and measures because wehave so many people who draw blood, and we implemented those things, and ofcourse our exposures related to phlebotomy declined.
Pam Gill, RN, BSN, HIVprevention nurse at Statesville, N.C.-based Iredell Memorial Hospital, alsoadvocates the proactive identification of devices that may be more suitable andsafe. Recently, Gills facility made a change in their Huber needles based onfront-line clinician initiative.
We already had a safety Huber needle in place, but our mostexperienced staff who used Huber needles came to us and they had seen a new oneat a conference and were interested in trying it, says Gill. So we broughtthat in and did the training with a small group of people, which was ouroutpatient nursing center here. They wanted to try it, so we did a trial just inthat department because they are the biggest users of that product.
Clinician feedback was collected, and patient reactions weretaken into consideration as well. That was wonderful, because if youve gotthe nurses who say its a good product, and patients are also saying they likeit, then we think we really have a winner, Gill says. Once we got theevaluations back, we knew we wanted to implement it in the other areas of thehospital that used Huber needles, so we used that department as our go-topeople.
As other departments were trained, they were able to contactthe clinicians who had originally evaluated and used the new products if theyencountered any problems or questions. Thats great when you have access toanother department whose staff kind of becomes your experts with a product,Gill notes. It also makes the rest of the staff more comfortable if theirpeers are saying they have used the product and like it, and heres how you doit safely. So that product was probably one of the easiest to bring in that Ivedone in a long time, because it started with the users themselves wanting toimplement it and evaluate it and then they were the contact people when weimplemented it house-wide.
As dictated by theOccupational Safety and Health Administration (OSHA), the evaluation of new andinnovative safety products is an ongoing effort in many facilities, even whenneedlestick exposure rates are low.
Diane Baranowsky, RN, nurse epidemiologist at Stamford,Conn.-based Stamford Hospital, is the chairperson of her facilitysmultidisciplinary safety needle device task force, which seeks to addressproblem areas in terms of sharps injuries, and also constantly reviews newproduct information. Our goal is to be in compliance with the OSHA mandate,which is prevention of needlesticks to our healthcare workers, so one aspect ofthat is that we look at our pre-packaged kits or trays that are prepared by ourvarious vendors and we solicit information from them as well.
Baranowsky explains that the task force continually searchesfor input and feedback from HCWs to help identify potentially helpful products.We solicit information both at a general orientation for our new healthcareworkers, to see what they are accustomed to using and what they recommend, andthen every month at the various in-service committees we solicit again whatproducts are out there, and what people think we need, she says. Then wellbring in a product, well evaluate it and make recommendations to trial it,and then trial it and purchase it based on the evaluations. Its amultidisciplinary effort.
The Centers for Disease Control and Prevention (CDC) supportsthe idea of a multidisciplinary leadership team when it comes to sharps injuryprevention. The team should include representatives from many departments withinthe facility, including:
Recently, this effort led Baranowskys facility to evaluateand purchase a needleless wound closure product. The product was evaluatedand trialed by the physicians in our immediate care/walk-in area, so it was forthe superficial skin injuries, she explains. It was trialed and purchasedfor that area, and it is presently being evaluated by our chief of OBGYN for use on the surgical patients in that area.
Although her facilitys existing wound closure product wasalso needleless, Baranowsky says the determination was made that there was stillroom for improvement. Wed had a liquid binder to replace suturing, soagain our goal is needlestick prevention and were trying to be proactive,which includes being cognizant of the various products on the market.
The OR Neutral Zone
Although theimplementation and correct usage of various classes of safety devices is a vitallink in the chain of promoting sharps safety, education also plays a major role,and must be constantly evaluated and reinforced. An example is in the OR youve got to use a neutral zone, says Steed. Thats not a needle ordevice; its a zone where you set sharps. That takes major behaviormodification, especially in our hospital system, where we have about 600surgeons. In our OR experience, the neutral zone was the major emphasis, eventhough there were other things as well. We did implement some safety devices,but the biggest thing was the implementation of the neutral zone.
The scope of this effort was enormous, as Steed recalls. Itwas a major challenge and it took several years to get anywhere, because you hadto continually repeat and repeat and repeat, but our surgical technicianexposure rate has dropped tremendously, she says.
The need for education in this area was identified by carefulanalysis of exposure data. We focused on the surgical techs a couple yearsago because they were our healthcare professional group that was exposed most;their exposure rate was tremendously higher than any other group, Steedcontinues. Their numbers werent higher, but their rate of exposurewas higher.
After investigating the potential cause of these high rates, acourse of action was decided upon. Quite frankly, they were getting stuck because of thesurgeons, so we had to focus on behavior modification with the surgeons andtechnicians, and that led to tremendous improvement, Steed says. We foundthat the best way to get the surgeons is to set up tables, so we set up a tableright by the door where they go in to change into scrubs. We put a table thereand we put different things that could serve as a neutral zone on it wewanted their input on what they could use, and at the same time we wereeducating them about the need for the neutral zone.
Resistance to change can be a significant hindrance in a largeinitiative such as this, and Steed contends that hard numbers are a necessity incommunicating the need for new procedures. We showed them the data weshowed them that they were sticking people and that in order to keep that fromhappening, a neutral zone needed to be used, she says. Thats how theeducation occurred, but what we found is that it had to be done consistently andin an ongoing fashion over about a year. At the same time, we had the OR nursemanagers monitoring the use of the neutral zone, and when they didnt see theuse of the neutral zone, they said something about it. They still do that today.That monitoring by the management staff is one of the most important things thathas helped.
Staying abreast of changes in technology and behavior andevaluating them relative to a facilitys own unique circumstances must involvedata, according to Steed. Weve been very successful here, shecontinues. New things and new trends come up, and thats why youhave to have data. You cant say, Ive got my safety device, so I donthave to worry about it anymore, because things can happen. So you have tomonitor your data, and if a problem occurs, your data helps you to figure outwhats going on so that you can focus on it.
Needleless IV Access
The journeytoward needleless IV delivery systems was significant in terms of reducingexposures at Gills facility. When we quit using needles in our IV lines,our stick rate just dropped drastically; it made such a big difference in thesticks we were getting at the bedside accessing IV lines, she says.
Gill explains that she and her colleagues began constructingtheir own set-ups long before fully needleless IV systems were introduced. We started piecing together ports where you could access itwith a syringe and not have to put a needle in a port, so thats how long agowe started to put it together, she recalls. We just got things in bits andpieces and tried to make it as safe as possible, and we would put these caps onthe ends of our IV lines and the Y-ports in our IV set-ups so that we wouldnthave to stick a needle in them.
As new and better technologies in this area were evaluated andpurchased, safety rates improved even more. However, Gill is quick to point outthat acquiring the best devices is only part of the equation. Its a wholeprocess, she says. You cant just throw products out there and say usethese theyre safe, I just dont believe in that. You have to staywith your practice and education, because you can still get stuck with safetyproducts.
To Gill, effective education means making sure that everyclinician who will be using a new device is competent and comfortable with it.The follow-up is important for those who never quite got the technique down,who maybe needed just a little more time with the product in their hands, shesays. When youre trying to prevent sticks, you dont wanteven one, so that person who got left behind in technique, thats the reasonyou follow up continually, and you have to watch them and pick them out.
Gill goes on to describe an example in which she wasevaluating nurse competency with a certain device. One nurse in particularseemed to be having some trouble mastering the technique. I watched her doit, and it was very awkward what she was doing, and I could see that she waseasily going to be stuck, so I said to her, Let me show you how to do thisthen I want you to do it again, Gill relates. After taking the time towork with the nurse and communicate about the technique, Gill discovered thatthe nurse was left-handed and was attempting to use her right hand as thedominant hand since she was told to perform the technique exactly as the personwho taught her had done. So it could be something as simple as that, Gillexplains. If you can uncover things like that, it demonstrates the importanceof the follow-up and being there for them and watching them do it again and again.
1. NIOSH Alert: preventing needlestick injuries in healthcaresettings. DHHS (NIOSH) Publication 2000-108.
2. Lee, JM, et al. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN J.2005 Mar;53(3):117-33. Review.
3. Occupational exposure to bloodborne pathogens; needlestickand other sharps injuries; final rule. Occupational Safety and HealthAdministration (OSHA), Department of Labor. Fed Regist. 2001 Jan18;66(12):5318-25.
4. CDC. Workbook for Designing, Implementing and Evaluating aSharps Injury Prevention Program, p. 1.