Cover
Story
Worker safety demands strong policies, safe products and some luck
by Curt Werner
 From the moment that the determination is made that a patient requires some sort of injection, the decision puts into motion a sequence of events that could result in either an unremarkable, routine medical procedure or the first minutes of what could be a horrific, life-threatening set of circumstances for the caregiver. Because of the chance of accidental needlestick and the potential danger it brings, the difference between the routine and the extraordinary rest every day literally on the tip of a needle.
The first years of the HIV/AIDS crisis swept away not only thousands of lives, but also much of the naivety attached to what may be history’s most common medical procedure. No more casual injections or tossing used needles into the trash, even inadvertently. Even more recently that the onset of HIV/AIDS and the gathering storm of hepatitis, legislation has been enacted that mandates that healthcare workers at least have a choice in the needle products they use. That’s revolutionary. Because when a nurse or other caregiver gives an injection or takes blood or starts an IV, then pulls that needle from the patient, the value of a needle safety product proves its worth.
 In November 2000, the Occupational Safety and Health Administration, which estimates that a staggering 600,000 to 800,000 percutaneous exposure incidents occur each year, enacted the groundbreaking needle safety law as an amendment to the bloodborne pathogen standard. During the first year, compliance, particularly in the nation’s physician’s offices, was spotty, and reports are that in those settings those dangerous old habits are dying hard. In hospitals, however, probably because of better finances and supportive educational efforts from infection control and nursing staffs, more providers are using needle safety products than ever before. The Centers for Disease Control estimates that each year accidental needlesticks lead to 800 cases of hepatitis B and more than 1,000 cases of hepatitis C. In addition, 191 documented and possible cases of HIV infection have been attributed to the use of unshielded needle devices.
The new federal rules come with some bite in the form of stiff fines for providers that at least have failed to offer needle safety products to their staff members. Still, some hospitals persist and OSHA is said to be coming down hard on those facilities. Levies of as much as $70,000 per occurrence are mandated, and federal regulators are turning up the heat on needle safety scofflaws, stepping up inspections and handing out more than a million dollars in penalties. Between July 2001 and May 2002, OSHA investigators wrote a stunning 1,876 citations to healthcare facilities judged in violation of the law. What’s more, only about one-fifth of the costly inspections were prompted by an employee complaint, a figure that confounds expectations.
The CDC believes that 62 to 88 percent of sharps injuries can potentially be prevented by the use of safer medical devices. These injuries affect healthcare workers in many areas of the hospital. One area recently surveyed was the emergency department, an area of particular vulnerability, doubly so in inner city neighborhoods. According to figures published recently by the authoritative International Health Care Worker Safety Center at the University of Virginia, one study looking at inner city patients found an astounding 24 percent were infected with at least one of a group of pathogens including HIV, hepatitis B and hepatitis C. Even more dangerous is the revelation that more than two-thirds of those infected patients were not identified in the hospitals that treated them. Recent figures contained in an EPINet report (“Percutaneous injuries and blood exposures in emergency department settings,” Advances in Exposure Prevention, Vol. 6, No. 2, pg. 1) point up the problem. An EPINet survey of 95 emergency department workers at a university teaching hospital had an average of 56.5 blood and bodily fluid contacts per year, but just 4 percent reported their most recent contact. The report goes on to say that in all other hospital settings, 24 percent of injuries are from blood-filled needles, while in emergency departments, that figure is 42 percent.
It’s easy to tell from the accompanying graphics that sharps injuries can take place virtually anywhere in a healthcare facility and while utilizing a wide variety of devices, which means healthcare workers must be constantly on the alert for accidents. Scores of manufacturers are now offering safety devices, and most experts say that most of the devices have value. At the risk of omitting names from a list, among the significant manufacturers are Bard Medical, Covington, GA; B.Braun Medical, Allentown, PA; BD, Franklin Lakes, NJ; Deltec USA, St. Paul, MN; Ethicon Endo-Surgery, Vascular Access, a Johnson & Johnson company based in Cincinnati; Horizon Medical, Dickson, TN; and Retractable Technologies Inc., Lewisville, TX.
The various device categories have within them specific uses as well. One is B.Braun’s new Surecan Safety Huber Needle Infusion Set, due to be released this spring. Jeff Chiesa, the company’s product director for IV systems, says the product consists of a standard right angle noncoring Huber needle with a passive safety mechanism clip, hub grip, base plate, extension set with an on-off clamp and a female luer lock connector. According to B.Braun’s 510(k) information, the safety clip mechanism is designed to reduce the risk of accidental needlestick injuries by shielding the needle. The safety clip mechanism will activate once the Huber needle is pulled from the base plate. Surecan is a passive needlestick prevention device that is designed to minimize inadvertent needlesticks. The device is intended to provide implanted subcutaneous port access, used in conjunction with IV administration of chemotherapy and other injectable drugs and/or to withdraw blood. The product is aimed at procedures, many of them performed on an outpatient basis, involving patients suffering from AIDS and cancer, as well as those in need of chronic IV therapy.
The design of the Surecan would seem to make it a natural for rapid adoption in the marketplace. But Chiesa says that despite the availability of the B.Braun device and others, standard injection devices are still in use in many facilities. “I’m a little surprised at this, especially with the amount of legislation that has been passed,” he says. B.Braun still sells the older, lower tech, standard units along with its safety devices.
 In most cases, blame price considerations as the reason why such safety products are not in more widespread use. As a group, safety devices cost significantly more per unit than standard needles. However, those favoring safety devices point out the economic and human costs of needlesticks, which far outstrip transactional costs of the products themselves. Says Chiesa, “There is a perceived cost issue and that trend is continuing. But once a facility brings in needle safety devices it never goes back. A small portion of hospitals use standard injection devices, but the usually have taken no risk assessment of the cost of treating a needle stick. These facilities probably don’t have an infection control department either.”
AHA’s 12 steps to sharps safety
The American Hospital Association’s guide on preventing sharps injuries offers the following recommendations:
- Communicate your facility’s commitment to a safe environment for patients and workers.
- Assign a point person to oversee sharps injury prevention efforts.
- Establish a multidisciplinary team, including representatives from infection control, risk management, materials management, nursing, occupational health, and frontline workers.
- Gather information on current use and availability of safety devices in your facility.
- Collect data and identify devices/areas/uses/staff with the greatest risk of exposure to bloodborne pathogens.
- Select targeted devices for replacement.
- Meet with vendors to identify and choose safety devices to test.
- Pilot-test safety devices for their effect on patients and health care workers.
- Select safety devices to replace targeted devices.
- Teach and train all staff using the new safety devices.
- Replace existing devices with safety devices, following training.
- Collect data periodically on safety devices to evaluate their impact on worker injury rates and patient safety.
*Source: Centers for Disease Control National Surveillance System for Hospital Health Care (International Health Care Worker Safety Center, 1997; EPINet, 1999; CDC unpublished data, 1999)
From
OSHA, some useful definitions:
Engineering controls
Engineering controls include all control measures that isolate or remove a hazard from the workplace, such as sharps disposal containers and self-sheathing needles. The original bloodborne pathogens standard was not specific regarding the applicability of various engineering controls (other than the above examples) in the healthcare setting. The revision now specifies that “safer medical devices, such as sharps with engineered sharps injury protections and needleless systems” constitute an effective engineering control, and must be used where feasible.
Sharps with engineered
sharps injury protections
This is a new term which includes non-needle sharps or needle devices containing built-in safety features that are used for collecting fluids or administering medications or other fluids, or other procedures involving the risk of sharps injury. This description covers a broad array of devices, including:
- Syringes with a sliding sheath that shields the attached needle after use.
- Needles that retract into a syringe after use.
- Shielded or retracting catheters.
- Intravenous medication (IV) delivery systems that use a catheter port with a needle housed in a protective covering.
Needleless systems
This is a new term defined as devices that provide an alternative to needles for various procedures to reduce the risk of injury involving contaminated sharps. Examples include:
- IV medication systems which administer medication or fluids through a catheter port using non-needle connections.
- Jet injection systems that deliver liquid medication beneath the skin or through a muscle.
Internet resources
The OSHA Bloodborne Pathogens Standard
(29 CFR 1910.1030) gives workers important protections to prevent needlesticks and other types of exposures to blood at work. The full text of the standard is located on the OSHA website at
www.osha-slc.gov/OshStd_data/
1910_1030.html.
OSHA directive (11/99):
www.osha-slc.gov/html/
ndlreport052099.html
OSHA’s Revised Bloodborne Pathogens Standard – Published 1/18/01:
www.osha-slc.gov/FedReg_osha_data/
FED20010118A.html
OSHA Directives – Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens:
www.osha-slc.gov/OshDoc
/Directive_data/CPL_2-2_44D.html
OSHA Bloodborne Pathogens Module:
www.osha-slc.gov/SLTC/
nursinghome_ecat/bbp/bbp.html
OSHA FAQs about needlestick injuries:
www.osha-slc.gov/needlesticks/
needlefaq.html
CDC Safety Alert (through NIOSH, 11/99):
www.cdc.gov/niosh/2000-108.html
OSHA Needlestick Prevention:
www.osha.gov/SLTC/needlestick/
OSHA Subject Page for
Needlesticks: www.osha-slc.gov/needlesticks/
index.html
Preventing needlestick injuries in healthcare settings:
www.cdc.gov/niosh/pdfs/2000-108.pdf
OSHA’s Safer Needle Devices – Protecting Healthcare Workers:
www.osha-slc.gov/SLTC/needlestick
/saferneedledevices/
saferneedledevices.html
CDC Health Topic –
Needlesticks: www.cdc.gov/health/needlesticks.htm
OSHA toll free number: (800) 321-OSHA (6742)
Filing a complaint with OSHA
An OSHA Complaint Form is in Appendix C. The form is available on the OSHA Web page at
www.osha.gov/oshforms/osha7.pdf.
Check with your state’s safety and health agency for a copy of the form used where you are located.
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