OBJECTIVES
1. Determine your facility's existing sharps
injury prevention program.
2. Identify how to develop and implement improvements on the program.
3. Evaluate the result of the new, improved program.
Most healthcare facilities by now have
implemented some sort of prevention program for sharps injuries.
However, newer guidelines and evidence of other facilities' successes
and failures mean that it may be time to re-evaluate and re-design your
own plan.
In 2004, the Centers for Disease
Control and Prevention (CDC) released its Workbook for Designing,
Implementing, and Evaluating a Sharps Injury Prevention Program. The
workbook, available free of charge on the CDC's Web site at www.cdc.gov/SharpsSafety,
clearly outlines each step required in the process of reworking your
sharps injury prevention program (SIPP).1
Injuries from needles and other sharps
devices are, for the most part, preventable. Rushing, taking shortcuts,
avoiding the use of safety features on safety devices -- each of these
steps dramatically increases the chances of acquiring an injury in the
workplace. The CDC estimates that there are 385,000 needlesticks and
other sharps-related injuries to hospital-based healthcare workers each
year. In addition, similar injuries occur at other healthcare-related
settings, such as clinics, ambulatory surgery centers, and nursing
homes.
These numbers are staggering,
especially when considering the possibilities created by a sharps injury
-- acquisition of hepatitis B virus (HBV) or hepatitis C virus (HCV),
human immunodeficiency virus (HIV) or other bloodborne pathogens.
However, it is possible to reduce these
incidents, merely by adopting recommendations that combine with existing
programs for performance improvement, infection control and safety. The
CDC describes its model as "a systematic, organization-wide
approach for continually improving all processes involved in the
delivery of quality products and services." It incorporates two
elements -- organizational steps to develop and implement a SIPP, and
operational processes.
The workbook is designed to assist
healthcare facilities in meeting worker safety requirements for
accrediting organizations, as well as regulatory standards for the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO), the
Center for Medicare and Medicaid Services (CMS), the Occupational Safety
and Health Administration (OSHA) bloodborne pathogens standards,
state-mandated OSHA plans, state-specific legislation and the Federal
Needlestick Safety and Prevention Act.
The Cost of Sharps Injuries
Because employees with a sharps injury
must undergo both initial and follow-up treatment after a
"stick," costs of these treatments can range from $500 to
$3,000 per incident; however, these costs do not include the emotional
toll on the employee, drug toxicity and lost time from work, and the
cost to society if there is a seroconversion to HIV or HCV, which may
include the worker's inability to work with patients, the cost of
medical care for these conditions, or the cost of litigation due to the
stick or the seroconversion.
Who Is at Risk?
Data from the National Surveillance
System for Healthcare Workers (NaSH) indicate that nurses suffer the
greatest number of percutaneous injuries. But other groups at risk
include patient care providers such as physicians and technicians,
laboratory staff, and support personnel such as housekeeping. Although
nurses have the greatest numbers, simply because they are often the
largest division of the hospital staff, non-nursing job roles sometimes
reflect a higher rate of injury when injury rates are calculated based
on the number of employees.
Similar statistics can be found on the
International Health Care Worker Safety Center Web site at
www.healthsystem.virginia.edu/internet/epinet. This data is provided by
hospitals participating in the Exposure Prevention Information Network
(EPINet) system.2
Sharps-related injuries tend to occur
mainly on inpatient units; 40 percent of incidents occur specifically on
medical floors and in intensive care units (ICUs), and in operating
rooms (25 percent).
These events generally occur
"after use and before disposal of a sharp device (41 percent),
during use of a s harp device on a patient (39 percent), and during or
after disposal (16 percent)," says the CDC workbook.
"Aggregate data from NaSH indicates that six devices are
responsible for nearly 80 percent of all injuries. These are:
- Disposable syringes (32 percent)
- Suture needles (19 percent)
- Winged steel needles (12 percent)
- Scalpel blades (7 percent)
- Intravenous (IV) catheter stylets (6
percent)
- Phlebotomy needles (3 percent)
"Overall, hollow-bore needles are
responsible for 59 percent of all sharps injuries in NaSH."
Not surprisingly, research has also
found that the highest rates of injury were associated with devices that
required manipulation or disassembly after use -- i.e., needles that
were attached to IV tubing, winged steel needles, and IV catheter
stylets.3
Hollow-bore needles are the largest
concern -- especially if they are used for blood collection or IV
catheter insertion. "These devices are likely to contain residual
blood and are associated with an increased risk for HIV
transmission," the workbook points out.4
Preventing Injuries
Prevention strategies have evolved
since recommendations in 1981 by McCormick and Maki5, which
included education, avoidance of recapping, and better disposal system
for sharps. In 1987, the CDC added to this list by recommending careful
handling and disposal of risky devices.6 Additional studies
recommended designs and placement for puncture-resistant sharps
containers, as well as education on risky procedures such as recapping,
bending, and breaking used needles.7, 8, 9, 10, 11, 12, 13
"Universal (now standard)
precautions is an important concept and an accepted prevention approach
with demonstrated effectiveness in preventing blood exposures to skin
and mucous membranes. However, it focuses heavily on the use of barrier
precautions and work-practice controls, and by itself could not be
expected to have a significant impact on the prevention of sharps
injuries," the workbook reports. "Although personal protective
equipment (PPE) provide a barrier to shield skin and mucous membranes
from contact with blood and other potentially infectious body fluids,
most protective equipment is easily penetrated by needles. Thus,
although strategies used to reduce the incidence of sharps injuries
(e.g., rigid sharps disposal containers, avoidance of recapping) a
decade or more ago remain important today, additional interventions are
needed.
New Interventions
Newer interventions include the
elimination and reduction of sharps as much as possible, as well as
protecting the sharp with an engineering control. Beyond these two
steps, it is necessary to utilize work-practice controls and PPE. The
federal government has assisted by making these first two interventions
required by law. The federal Needlestick Safety and Prevention Act in
November 2000 mandated specific use of safety-engineered sharps.
Steps to Prevention
To radically reduce the number of
sharps injuries, several steps are necessary.
- education
- reducing invasive procedures
- a secure work environment
- an adequate staff-to-patient ratio
- formation of a prevention committee
for compulsory inservices
- outsourcing the replacement and
disposal of sharps containers
- revision of existing needlestick
policies
- adoption of a needleless IV access
system, safety syringes, and a prefilled cartridge needleless
system.
The American Hospital Association
states that such programs also require:
- Comprehensive injury reporting
- Follow-up
- Education in new devices
- Evaluation of their effectiveness14
The end result of taking these steps is
a savings to the facility in terms of money as well as employees. A
"strong safety culture" increases employee satisfaction, the
workbook reports, as well as productivity.15
Organizational Steps
It is first necessary to develop the
organizational capacity -- the program must be instituted throughout the
facility. "Responsibility is held jointly by members of a
multidisciplinary leadership team that is focused on eliminating sharps
injuries to healthcare personnel," the workbook says.
"Representation from senior-level management is important to
provide visible leadership and demonstrated the administration's
commitment to the program. The team should also include persons from
clinical and laboratory services who use sharp devices, as well as staff
with expertise in infection control, occupational health/industrial
hygiene, inservice training or staff development, environment services,
central service, materials management, and quality/risk
management."
First, the team must establish an
action plan for reducing injuries, then establish an action plan for
performance improvement. These require:
Injury Reduction
- setting targets for injury reduction
- specifying which interventions
should be utilized
- identifying indicators of
performance improvement
- establishing time lines and defining
responsibility
- erformance Improvement
- listing priorities for improvement
- specifying which interventions will
be used
- identifying performance improvement
measures
- establishing timelines and
delineating responsibilities
Second, the team must institute a
safety culture throughout the facility, execute procedures for reporting
and examining injuries and hazards, analyze injury data for both
planning and performance improvement, select appropriate safety devices,
then educate and train staff on prevention of sharps injuries.
The third step is establishing a
baseline profile of risks throughout the institution. Next, prioritize
the risks to determine which will be rectified first. Fifth, develop and
implement the action plans; sixth, monitor performance improvement.
Safety Culture
A safety culture reflects a
"shared commitment of management and employees to ensure the safety
of the work environment." Such a culture originated in the
manufacturing sector, where research indicated the necessity of
managerial involvement in safety programs, high status for safety
officers, strong training and communication, of orderly operations, and
emphasis on individual performance, rather than on punitive measures.
Evidence shows a reduction in exposure to blood and body fluids, as well
as a reduction in sharps injuries, when this culture is in place.
Procedures for Reporting and
Examining Injuries and Risks
It is crucial to have accurate data on
both injuries and injury hazards to establish proper prevention
planning. Staff members need to understand what to report, how, and
when. Establish a protocol for reporting and documentation; the protocol
should establish where to seek medical evaluation and treatment after an
injury. It should also establish how soon it must be reported, as well
as how to obtain medical treatment for the injury during each work
shift. Medical privacy must be maintained for each exposed employee;
however, occupational health or infection control should retain exposure
reports for follow-up and record-keeping.
Provide a standard reporting form that
includes information about the brand and manufacturer of the device,
including how it contributed to the injury -- design flaw, defect,
failure, operator error, or other events such as patient movement.
Hazard reporting is also necessary --
this includes "near misses." There must be a procedure
established for evaluating what led to an injury or a near miss, such as
a flow chart, cause/effect diagram, affinity diagram or root cause
analysis.
Analyzing Injury Data
Prevention planning requires quality
sharps injury data, which can be compiled by hand or with a database.
Determine the occupations of injured personnel, their work locations
during the injury, the type of device involved, the type of procedure
involved, the timing of the injury (before use, after use, before
disposal), and what led to the injury. Then calculate injury incidence
rates.
Selecting Prevention Devices
The next step is choosing devices that
will reduce the number of injuries received from sharps. It is necessary
to organize a product selection/evaluation team, determine what factors
are most important in a safety device, get information on the existing
device that is being replaced, choose the products to evaluate, obtain
samples, develop a product evaluation form and plan, tabulate and
analyze results, select and implement the chosen product, then monitor
the effects of the implementation.
Educating and Training Staff
Sharps injury prevention training can
be provided during the initial orientation to the facility, during
annual bloodborne pathogens training, during staff development training
on procedures, and during the introduction of new devices. Specific
information about the facility and its recent numbers of sharps injuries
is useful, as is data on which occupations, devices and procedures were
associated with the most risk. Offer staff the "hierarchy of
controls," which includes:
- strategies to reduce the use of
sharps
- devices with safety features
- other engineering controls (such as
sharps disposal containers)
- work practices to reduce risk
- PPE to reduce risk.
Case studies of exposures -- with the
worker privacy protected -- can be useful, as well as a discussion of
how the specific injury could have been prevented.
Tools for Improvement
The CDC offers a toolkit with multiple
worksheets, which provide a means of establishing a baseline, conducting
employee surveys, calculating injury rates, and evaluating devices.
These forms are available at www.cdc.gov/SharpsSafety/appendixA.html.
The National Alliance for the Primary
Prevention of Sharps Injuries provides a list of both primary and
secondary prevention devices at www.nappsi.org/safety.shtml.
Other sources include the U.S. Food and
Drug Administration, at www.fda.gov/cdrh/devadvice;
the Government Accounting Office report on costs of safer needle devices
at www.gao.gov/new.items/d0160r.pdf;
the International Healthcare Worker Safety Center at www.med.virginia.edu/medcntr/centers/epinet;
and the International Sharps Injury Prevention Society at www.isips.org.
Additional links are listed on the CDC's Sharps Safety site.
A sharps injury prevention program does
not have to be an overwhelming, expensive task. Take advantage of the
numerous sources that are available, free of charge, to improve your
facility's overall safety, employee satisfaction, and infection control.
References
1. www.cdc.gov/SharpsSafety
2. www.healthsystem.virginia.edu/internet/epinet/
3. Jagger J, Hunt EH, Brand-Elnaggar J,
Pearson R. Rates of needlestick injury caused by various devices in a
university hospital. N Engl J Med 1988;319:284-8.
4. Cardo DM, Culver DH, Ciesielski CA,
Srivastava PU, Marcus R et al. A case-control study of HIV
seroconversion in health care workers after percutaneous exposure. N
Engl J Med 1997;337:1485-90.
5. McCormick RD, Maki DG. Epidemiology
of needle-stick injuries in hospital personnel. American J Med
1981;70:928-932.
6. CDC. Recommendations for prevention
of HIV transmission in healthcare settings. MMWR 1987;36(Suppl):1-18.
7. Ribner BS, Ribner BS. An effective
educational program to reduce the frequency of needle recapping. Infect
Control Hosp Epidemiol 1990;11:635-8.
8. Ribner BS, Landry MN, Gholson GL,
Linden LA. Impact of a rigid, puncture resistant container system upon
needlestick injuries. Infect Control 1987;8:63-6.
9. Linnemann CC, Jr., Cannon C, DeRonde
M, Lanphear B. Effect of educational programs, rigid sharps containers,
and universal precautions on reported needlestick injuries in healthcare
workers. Infect Control Hosp Epidemiol 1991;12:214-9.
10. Sellick JA, Jr, Hazamy PA, Mylotte
JM. Influence of an educational program and mechanical opening needle
disposal boxes on occupational needlestick injuries. Infect Control Hosp
Epidemiol 1991;12:725-31.
11. Edmond M, Khakoo R, McTaggart B,
Solomon R. Effect of bedside needle disposal units on needle recapping
frequency and needlestick injury. Infect Control Hosp Epidemiol
1988;9:114-16.
12. Smith DA, Eisenstein HC, Esrig C,
Godbold J. Constant incidence rates of needle-stick injury paradoxically
suggest modest preventive effect of sharps disposal systems. J Occup Med
1991;34:546-51.
13. Haiduven DJ, DeMaio TM, Stevens DA.
A five-year study of needlestick injuries: significant reduction
associated with communication, education, and convenient placement of
sharps containers. Infect Control Hosp Epidemiol 1992;13:265-71.
14. American Hospital Association.
Sharps injury prevention program: a step-by-step guide. (Pugliese G,
Salahuddin M, eds.) Chicago: 1999.
15. Gershon R. Facilitator report:
bloodborne pathogens exposure among healthcare workers. Am J Ind Med
1996;29:418-20.
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