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By Karen A. Daley, Angela K. Laramie, and Amber H. Mitchell
Since passage of the federal Needlestick Safety & Prevention Act (NSPA) more than 16 years ago, progress has been made in sharps injury (SI) prevention with fewer injuries and more widespread use of sharps devices with engineered SI prevention features. However, significant and persistent concerns that remain brought together sharps safety experts along with representatives from device manufacturers and distributors who provided sponsorship for the July 2017 meeting held at the American Nurses Association (ANA) headquarters in Silver Spring, Md. This summary of the SI Prevention Stakeholder Group meeting discussions and workgroup reports offers a glimpse into some of the ongoing concerns related to SI prevention across the U.S.
The national SI Prevention Stakeholder Group was established and convened in the spring of 2015 with support from the ANA as part of its continuing efforts to enhance worker safety – a concept linked both to patient safety, staffing and the health and well-being of staff. The group meets quarterly via conference call during which participating experts network, share updates and collaborate in activities focused on SI prevention. The group is co-chaired by Dr. Karen Daley, a past president of the ANA, Dr. Amber Mitchell, president and executive director of the International Safety Center, and Angela Laramie, epidemiologist and coordinator of the Sharps Injury Surveillance Project at the Massachusetts Department of Public Health (MDPH). Included among the group’s members are representatives of state and federal government, academia, research, advocacy, professional organizations, organized labor, and manufacturing, including members from the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH), the Centers for Disease Control and Prevention (CDC), the Department of Veterans Health Affairs, the International Safety Center, Healthcare without Harm, the Association of Occupational Health Professionals in Healthcare, the American Association of Occupational Health Nurses, and the Association of periOperative Registered Nurses (AORN).
Since 2015, discussion topics have included: ongoing OSHA Bloodborne Pathogens Standard compliance gaps; OSHA enforcement issues; the lag of SI reduction within general and perioperative settings; the growing list of bloodborne pathogens including emerging pathogens like Ebola and Zika; downstream injuries and occupational bloodborne pathogen exposures in non-hospital settings; lack of effective national surveillance systems for work-related SIs and seroconversions or subsequent disease development; and the inconsistent and confusing nature of terminology used to describe devices with SI prevention features. Also of serious concern to the group is what appears to be a plateauing of progress in SI reduction across the US since 2010 and a rise in the number of injuries occurring from devices with engineered SI prevention features (Mitchell et al., 2017)
In early 2017, the SI Prevention Stakeholder Group made the decision to focus on SIs in the operating room (OR) setting for the next 12 months. Operating rooms are unique hospital environments in many respects and have long been identified as one of the most hazardous hospital departments with respect to SI risk (Mitchell, 2017). In stark contrast to other hospital settings where a reduction in SIs has been demonstrated since passage of the NSPA, evidence suggests that OR SIs are actually increasing (Personal communication, MDPH unpublished data).
A number of factors likely account for the persistently large proportion of injuries within ORs, including the high prevalence of sharps use, the limited arsenal of and resistance to adoption of sharps devices with engineered SI prevention features, limited visibility within operative cavities due to blood volume as well as converging hands and instruments, communication challenges, crowding of surgical team members around patients, ergonomic issues, and frequency of emergent situations. It is also a setting where decisions related to instruments and work practices are often determined by one person – the lead surgeon – have a potential impact on the health and safety of all surgical team members as well as housekeeping and laundry personnel. In addition, injuries in the OR can result in cross-exposures, creating a clear and direct link between worker and patient safety.
The July 2017 meeting held at ANA headquarters represented the first opportunity for group members to meet face-to-face rather than by conference call thanks to contributions provided by device manufacturers and distributers who also attended the meeting. Companies represented included Ansell, Sandel Medical Solutions, B Braun Medical, BD Medical, Hill-Rom/Aspen Surgical, Retractable Technologies and RSS Medical Distributors. The following summary of discussions and workgroup progress reports during the July meeting offers a glimpse into some of ongoing concerns and discussions related to SI prevention across the U.S.
Three previously established workgroups comprised of stakeholder member volunteers provided updates during the 1½-day-long meeting. Workgroup topics included: OR injuries; safety sharps-related terminology, definitions and language; and sharps disposal and downstream injuries – defined as injuries occurring to those not initially using the devices. Open discussion followed each workgroup report.
The OR workgroup reported findings based on data collected and analyzed between 2010 and 2015 by staff from the International Safety Center and the Massachusetts Sharps Injury Surveillance System. The International Safety Center publishes aggregated Exposure Prevention Information Network (EPINet)) data submitted voluntarily by approximately 30 US hospitals and health systems. EPINet has been in use since 1992. Under Massachusetts state law, all hospitals licensed by MDPH are required to submit SI data annually to MDPH. Data have been collected each year from all MDPH licensed hospitals since 2002. Data elements from both the EPINet and MDPH surveillance systems are similar.
OR data findings from both surveillance systems for the period 2010 to 2015 approximated one another on a number of measures where similar data elements were collected. Those included overall sharps injury rates, OR SIs as a percentage of SIs hospital-wide, distribution of SIs by occupation, procedure, device, timing of injury, and presence of SI prevention feature. Figure 2 provides MDPH summary data describing ‘the how’ of reported OR SIs from 2010 to 2015. Findings also indicated about one-third of hospital-wide SIs occurred in ORs and as many as 80 percent of SIs involved devices without an engineered sharps injury protection mechanism. Physicians accounted for about 50 percent of OR injuries. Suture needles, hypodermic needles and scalpels remain the top three devices involved in SIs within ORs. Similar findings within these separate datasets provide strong evidence validating overall SI trends across the US during this period. This is further supported by personal interviews with OR staff.
The Terminology workgroup was formed in response to ongoing concerns around confusing and inconsistent terminology within publications, research, marketing materials and online resources related to sharps safety and devices. The diversity of current acronyms within the SI prevention literature and policy arena was described as awkward and the meaning of terms less than intuitive. Group support was expressed for a simplified approach to language and terminology, particularly regarding sharps devices with or without SI prevention features, and for working together to drive universal standardization of language. Additional discussion on terminology encompassed next steps for simplifying language. Strategies included: reaching out to communication and marketing professionals; considering packaging designs that would differentiate non-safety from safety engineered sharps devices; and considering whether new standards or directives could be created that might be used as models going forward.
The workgroup addressing disposal and downstream injuries was formed in response to ongoing challenges related to downstream injuries of non-users of sharps within and beyond hospital settings. Downstream injuries occur to non-users of the device and can include the receiver or intervener on a surgical team during device passing, environmental services, laundry personnel, and waste haulers, to name a few. EPINet findings relative to reported non-user injuries between 2010 and 2015 indicated more than 52 percent of downstream injuries occurred in ORs with 14 percent in patient rooms and 6% in emergency departments (See Figure 3).
OR nurses reported approximately 30 percent of recorded non-user injuries. Inactivation of sharps injury prevention mechanisms was associated with about 72 percent of reported downstream injuries. Improper disposal practices where devices were left on the floor, table or bed accounted for about 10 percent of the injuries. It was noted in the post-report discussion that environmental services and housekeeping staff are often affected by downstream injuries and are much less likely to report an injury or exposure. Possible explanations are that they may not be aware that the device was a contaminated sharp or that they work as contractors and may not have or be aware of a reporting mechanism. Among the additional reasons underlying non-users’ failure to report downstream injuries are feeling less a part of the team and fear of being blamed or fired from their job.
Common Themes Identified in Group Discussions
Discussions following workgroup reports identified a number of shared concerns. They included: unknown or underreported SI injuries and rates – especially within ORs; the need for institutional leaders and surgeons to champion and prioritize creation of safety cultures within all healthcare facilities, particularly the OR setting; the importance of rigorous state and federal OSHA enforcement of regulatory requirements under the Bloodborne Pathogens Standard; the importance of including frontline, non-managerial personnel in the evaluation and selection of devices with SI prevention features; ongoing education and training; and the need for inclusion of worker safety along with patient safety standards in assessments conducted by accrediting agencies such as the Joint Commission (TJC), particularly given the evidence that closely links worker and patient safety.
Universal support was also expressed among participants for incorporating SI prevention education into medical, nursing, and clinical/technical school curriculums as well as mandatory continuing education programs within practice settings. Other meeting discussions centered on the role attitudes, oppressive power hierarchies and lack of prioritization of worker safety cultures and climates by healthcare leadership can play in SIs. Additional factors identified that contribute to ongoing SIs across the U.S. include: proper worker education and training, staff failure to activate SI prevention mechanisms, and employer failure to engage frontline personnel in the evaluation and selection of devices with sharps injury prevention features. Participants stressed the importance of establishing peer-to-peer support as a necessary approach for changing attitudes and behaviors among those surgeons who currently undermine safety and SI prevention within ORs. The meeting concluded with identification of three actionable strategies to which meeting participants could realistically commit.
Summary of Next Steps/Actionable Strategies
Three new actionable strategies were prioritized and individuals committed to working in small groups to achieve specified outcomes. One work group will identify SI prevention standards and engage with accrediting and licensing agencies to encourage their adoption and incorporation as part of site surveys and/or inspection processes. Another workgroup will develop a media plan to raise public awareness of the associated risk to healthcare workers between SIs and preventable bloodborne pathogen exposures. The last new workgroup will create a “Safe OR” pilot program designed to model improved injury prevention within collaborating healthcare institutions utilizing designated staff surgeon champions. Stakeholder group members agreed to continue the existing workgroup focused on simplifying language and terminology related to sharps devices and safety. n addition, group members agreed to update the 2010 Consensus Statement and Call to Action (www.medicalcenter.virginia.edu/epinet/ConsensusStatementOnSharpsInjuryPrevention.pdf) sponsored by the International Safety Center (formerly International Healthcare Worker Safety Center) and published on the 10th anniversary of the NSPA.
Finally, all participants pledged their dedication to advocating for the prevention of SIs now and into the future – and not to let earlier progress in SI reduction detract from continued efforts to eliminate preventable injuries. Given the varied industries, backgrounds, and organizations of those present, all felt that continued collaboration among sectors was the best way to conquer this ongoing occupational health threat and its overall impact on public health. Future articles that will highlight our ongoing work are anticipated.
Karen A. Daley, PhD, RN, FAAN, is a nationally recognized sharps safety expert and policy advocate and served as president of the American Nurses Association from 2010-2014.
Angela K. Laramie, MPH, is an epidemiologist and has been the coordinator of the Sharps Injury Surveillance Project at the Massachusetts Department of Public Health since 2001.
Amber Hogan Mitchell, DrPH, MPH, CPH is the president and executive director of the International Safety Center. The Center is a 501c3 non-profit organization that provides the Exposure Prevention Information Network (EPINet®) to healthcare facilities around the world for free.
Mitchell A, Parker GB, Kanamori H, Rutala WA, and Weber DJ. Comparing Non-Safety With Safety Device Sharps Injury Incidence Data From Two Different Occupational Surveillance Systems.J Hosp Inf. Vol 96, No. 2, June 2017, pp. 195-8. http://www.sciencedirect.com/science/article/pii/S0195670117301184 https://doi.org/10.1016/j.jhin.2017.02.021
Mitchell A. The Changing Impact of Low PPE and Safety Device Use and Compliance in the OR. Infection Control Today. March 2017.