By Janice Larmouth, Director of Infection Control,
Southern New Hampshire Medical Center

Like many hospitals in the late 1990s, Southern New Hampshire Medical Center (SNHMC) in Nashua, NH, began to notice a trend—needlestick injury reports were increasing– perhaps the result of improved bloodborn pathogen exposure awareness or improved reporting practices. A few incidents in particular brought the issue to the fore: several SNHMC staff experienced percutaneous sticks with hollow-bore needles that involved HIV-positive or hepatitis B/C-positive patients. There were also a few high-risk sticks involving suture needles.

SNHMC, which dates back to the establishment of Nashua Emergency Hospital in 1891, in the basement of the Nashua Police Department, today extends across the city, with a downtown campus, a west campus and, located elsewhere in town, rehabilitation services. Its wide-ranging offerings include many that are not usually found in a community hospital setting, among them oncology services and neo-natal intensive care unit. SNHMC’s commitment to the greater Nashua community is matched by both the community’s trust in the medical center’s services and the staff’s confidence that it provides those services with the safest, most effective products available.

So, in March 2001, when needlestick injury reports started to rise, SNHMC began to initiate change. "We didn’t want to wait until the trend in needlesticks became an issue, or resulted in a serious injury that would affect not only that individual, but overall staff morale and behavior," says Jane McGettigan, SNHMC’s director of infection control at the time.

Though each occurrence at SNHMC was investigated and evaluated by the Employee Health Department, and recommendations were made for preventive measures, there still was very little concern or even awareness among staff. "It’s human nature not to feel at risk until something happens to people you know or even to yourself," says McGettigan. "Unfortunately, by time the latter happens, it’s too late."

According to the U.S. Department of Labor, nurses sustain the most needlestick injuries and as many as one-third of all sharps injuries occur during disposal. The Centers for Disease Control and Prevention (CDC) estimated in March 2000 that more than 380,000 percutaneous injuries from contaminated sharps occur annually among healthcare workers in US hospital settings. Of these sharps injuries, the CDC estimates that 62 percent to 88 percent can be prevented by using safer medical devices.

In 2001, the Occupational Safety & Health Administration (OSHA) updated its 1991 Bloodborne Pathogens Standard that protects workers from risk (research shows the standard has significantly reduced the risk that workers will contract bloodborne disease in the course of their work). The update required annual evaluations of safety equipment designed to prevent percutaneous injuries. To prevent further injury and maintain staff confidence at SNHMC, the center’s multidisciplinary Product Improvement Committee began to investigate alternatives to the suite of products it had been using for the past five or so years. One of the suppliers they turned to was BD (Becton, Dickinson and Company), who was known for the high quality of its safety-engineered products.

For SNHMC, switching to safety devices seemed like a natural progression—after all, the medical center had been using safety devices for IV therapy as far back as 1995. That changeover had added more than $100,000 to the IV therapy budget; at the time McGettigan’s department was asked to justify the expense. "We provided a graph that illustrated the reduction in injuries as each safety device was implemented," notes McGettigan. "We also provided data about the costs of treating each exposure, including staff time away from work. Data like this has been presented to SNHMC’s Safety Committee each year since 1996. Administration has continued to support the use of safety devices. The initial cost of the device may be greater than the non-safety product, but we do realize significant savings over time through injury reduction."

Although there was no dramatic incident McGettigan or anyone else could point to that propelled an investigation into alternatives to the variety of products SNHMC had been using for the previous five or so years, there was a growing concern. "We had provided safety devices for most of the other injection activities, such as IV therapy, phlebotomy and glucose monitoring, and we felt we needed to address this remaining area," says McGettigan.

Once McGettigan and staff decided to move ahead with choosing new products and implementing them into the system, they first had to identify a process by which this could occur.

SNHMC’s Product Improvement Committee reviewed the products that were available from vendors with whom it already had contracts and three products that looked promising were identified, among them the BD SafetyGlideTM shielding hypodermic needle. OSHA had by this time established the criteria for choosing new products. "We made sure that the products met those criteria," says McGettigan. "We also believed that it was essential for the new products to be acceptable to the staff who used them."

To winnow the choice further, and to involve the staff so they would feel not only part of the process, but part owners of it, the Medical Center held a Safety Product Fair in October 2001 and invited physicians, nurses and laboratory and respiratory therapy staff to attend and fill out evaluation forms about the three potential products. Two of the three virtually tied as the number one choice of staff.

Several months later, two trials were conducted using the two top-rated products that had almost tied in the evaluations. Staff members who participated in the trials were asked to complete an assessment form about each of the two products. Each assessment presented 15 "yes/no" (and "not applicable") statements and questions, ranging from "the safety
    Southern New Hampshire            feature can be activated using a one-
          Medical Center                  handed technique" to "the design of the product suggests proper use" to "does this product feel the same in your hand as a non-safety syringe?" In addition, the forms provided space for staff to add their own comments.

The choice and its implementation

The choice between the two products became easier when staff members voiced their opinions in favor of BD’s SafetyGlide product, which provides a manual mechanism to shield the needle after use. Staff was pleased that SafetyGlide syringes did not require a change in process—they could aspirate medication and administer injections accordingly to their usual technique. Further, this syringe’s Activation-Assist™mechanism allowed for single-hand activation of the safety shield. Those on staff who had been hesitant to change were won over to the BD product which was, many agreed, more compatible with the old product because it was from the same manufacturer.

Once the choice of the BD SafetyGlide had been made, SNHMC allowed a three month planning process and went department by department to identify those products to be removed, and discussed with staff how they should use the new product. "Once the choice was made the implementation process went into effect ‘cold turkey,’" McGettigan says. With assistance from three BD representatives, all of the remaining non-safety needles were replaced at once. The representatives also came in on all three shifts—over a 24-hour period—to help SNHMC implementation leaders educate about 240 staff members, including those in radiology and anesthesia, on the use of the safety devices.

Despite what seemed like a smooth transition, there were a few minor bumps in the road. There was some (as it turns out, misguided) concern that some on the staff would hoard the old products. The safety syringes were not compatible for two specific tasks—injecting topical anesthetics during surgical procedures and obtaining arterial blood gas samples. However, newer designs have addressed previous barriers for performing these tasks and BD-engineered safety devices are now available in virtually every clinical setting.

Success

This article was developed with the support of Jane McGettigan, SNHMC Director of Infection Control at the time the conversion took place, and Deanne Chapman, SNHMC Director of Employee Health.