The Changing Tides of Sharps Safety

When the Occupational Safety and Health Administrations (OSHA) bloodborne pathogens standard first came out in 1991, Pam Gill, RN, HIV/HBV prevention specialist with Iredell Memorial Hospital in Statesville, N.C., says they were on the right track in issuing the standards and recognizing a need for change, but at that time it was challenging for healthcare to respond due to the lack of safety devices that were then available.

You had to look at your policies and procedures and change work practice controls to make things safer because we didnt have the products at hand, Gill explains. Now, I think its easier because I think industry has seen that it is beneficial to them. She says the passage of the Needlestick Safety and Prevention Act and the enforcement of OSHAs standards have worked to not only gain recognition, but compliance too.

Today, Gill says manufacturers have responded with a plethora of safety products and devices. They are involving healthcare workers (HCWs) more now whereas years ago, HCWs really werent involved in the development of those products, she adds. When it all first began, she says it was often more of a hindrance to implement a product than it was beneficial because the people actually using the product were not involved in developing those products.

That has changed the way we use the products that are made now, she says, because HCWs are involved. It makes our job a lot easier when the technique that you are using goes with nursing process, nursing policy, and all of those things that we were taught years ago.

June M. Fisher, MD, director of the Training for Development of Innovative Control Technologies (TDICT) Project and associate clinical professor of medicine at the University of California, San Francisco, says there has been a sharp reduction in needlestick injuries since the momentum began, but she recognizes the need for more. We have reductions, but its not to zero, she asserts. We still have quite a way to go. The Centers for Disease Control and Prevention (CDC)s goal for 2010 is zero sharps injuries and we are not anywhere close to that.

She thinks this stems from a lack of appropriate safety devices as well as a lack of proper integration of the appropriate safety devices. We have from first- to third-generation devices and not everybody is using the better devices, she points out. Then we have some areas where devices havent been developed. And then we know that there are other ambient factors that go with the situation; one of them being staffing and long hours. Many institutions are still using first-generation devices and not implementing the better devices that are available. There have been a massive amount of devices coming on the market. Some of them are good and some of them are not good.

So what can a facility do to implement the correct safety products and continue to reduce needlestick injuries? Well, thats not a simple question to answer, Fisher says. One, you have to look at it systematically. We have a system, called task analysis, where you have to look at what you are using. What is on your wards and then what are you using for specific procedures? From there you have to go and see if there is a safety device for that device. Many times there is a safety device and you should be using that. And you should have a HCW involved in the process of looking at the device. It should be systematic and it should be for all devices. I dont think thats being done in most institutions. I think that purchasing is just introducing devices, whatever comes on the market that they are aware of if they are doing it.

Ive been asking for a long time that the HCWs are involved in looking at the devices in a systematic way, Fisher continues. Just to look at a device and say this is alright is not adequate. There is nothing that is most effective, she adds. Its a system. You have different components of the system; this is not magic. You cant get one device for everybody. Different units in the hospital require different devices. I know that to a manager this is a nightmare, but that is the only way it can be solved. Gill says there is a need for manufacturers to broaden their safety base. She says that while she recognizes industry has come a long way in developing usable safety products, much work still needs to be done. There are still things that I have asked for from manufacturers that I have yet to see. There are still some very high-risk areas. Dialysis is still very high risk. There are some safety products for dialysis, but I think that is an area that could be made safer. At the same time, I have learned that you have to be very careful that you are not putting patient safety at risk and sometimes the two can cross. There are so many products out there now that you really have to be careful that you have a good product for your staff member as well as a safe product for your patient.

Fisher offers advice on effective device selection. Our approach is that you have usability vs. effectiveness, and they are two different functions. Usability, is established by screening the devices. In that we recommend that the first thing that you do is you get every device that exists in that area when youre screening them. A bad device helps you. It lets you know very acutely what you dont want in a device. Then we read the published criteria; use written criteria to screen the devices first. It is a two-step procedure. Once you set up a system, it goes very rapidly. Look at all the devices in that category and youll probably come up with two or three that seem suitable using specific criteria like the TDICT criteria. Then you go to creating scenarios and simulations which are based on your task analysis. What looks good at the table may not look good when you simulate them. You then do a failure analysis where you try to destroy the devices. You drop them on the floor; you hit them against things; all the things that happen in reality. Then you get a pretty good idea about those things and then youre ready to do pilot testing. Fisher adds that she would like to see an effort in establishing a standardized national pilot testing guideline so that data can be pooled from different pilot testing sites.

Chris Milz, territory manager with Venetec International, says he works very closely with the HCWs in implementing Venetecs products. He says over the past three years he has been with the company, he has seen a clear change in HCWs willingness to adopt safety products throughout their facilities.

Milz also recognizes that the research that has been done over the past decade and a half has helped in raising awareness and in establishing a right of passage for safety device implementation. From my experience, most hospitals are interested in evidence-based practice, he explains. The regulatory support that we have has had a lot to do with the success that we have had. With all of that documentation, from such sources as OSHA, CDC, Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Infusion Nurses Society (INS), people are much more willing to listen to you and adopt products because it is not just our company recommending it. It is peer-reviewed studies from physicians and other people that say safety devices are the future.

Ive seen a lot of change in nurses and physicians as far as they are willing to go to evidence-based practice and replace habit-based practice because they see all the evidence. Now, they are not only willing to talk about it, but they are willing to adopt it. Milz works closely with Northside Hospital Systems in Atlanta, sharing information and allowing Northsides staff to trial his companys products.

At Northside, unless the product is specific to one area, the product will be trialed by the end users throughout the facility, according to Barbara March, RN, CRNI, supervisor of IV therapy with Northside. She notes that through working with industry representatives like Milz, and attending industry conferences, she doesnt see many areas where you cant get something that is not a safety product.

The more advantageous of the safety products are those that have eliminated the needle altogether. According to Fisher there should be still more strategies for eliminating sharps. If you go through the hierarchy of control thats used in occupational health and safety, the first thing is the elimination of a sharp, she asserts.

Milz agrees, adding those who have gone to Venetecs StatLock product, a needleless securement device, have seen a 100 percent reduction of accidental needlesticks, because you dont have the risk of a needle anymore, he says. Clinicians need to think more about taking a real serious look at where the industry is going, he adds. There is a reason why hospitals have adopted these securement devices. It is better for the HCW, the patient, and the hospital overall.

Still, more education, involvement, and change are needed. Fisher says some of the major focus areas today involve surgeons and other medical residents covering all the disciplines. I have been participating in a project with the Brooklyn VA where we have had dramatic decreases in the resident sticks, she shares. Weve gone from 23 in a period of time to two.

Thats by intensive education and making champions in the institution. We focus on training the chief residents who then take the responsibility, and its also creating a culture. Another area Fisher mentions that needs improvement and demonstrates a lack of safety devices is on the kits or trays used throughout the hospital. OSHA has been citing hospitals for using kits and trays without safety devices. Weve actually done a video, a trigger fi lm, for people to look at the kits and trays that NIOSH (National Institute for Occupational Safety and Health) is distributing. I think pressure needs to be on the packers who supply the trays; that they are supplying them with safety devices. She says the bulk of them lack safety devices and this needs to change.

Mary Bent Mangano, RN, MSN, clinical nurse specialist with Thomas Jefferson University Hospital in Philadelphia, says her hospital over the last year and a half has been working on just this. She says they are working to standardize all of their kits with safety devices. This is to implement a standard of care that would be the same across the house, she says. I use a safety needle. I also use a lot of the StatLock® products I have six of them to date. And these will be in all of our kits and that will be the standard of practice. We are in the process of converting more, in particular for the OR (operating room).

Mangano said they just had their fourth converted kit approved through their products review committee. The kit is for arterial lines. They also recently converted their anesthesia kit. A safety needle, ChloraPrep®, and the StatLock product. Those three components must be in those kits as my minimum standard of practice here, she adds.

Tried and True

Evelyn Hammond, RN, BSN, MSN, CNOR, OR nurse manager with Lexington Medical Center in Columbia, S.C., has been advocating sharps safety for a long time. In fact, she and her colleagues at Lexington have implemented an extensive sharps safety program.

Hammonds facility participated in the NIOSH Stop Sticks Campaign in 2004. The research project focused on disseminating information on needlestick prevention in different departments and in different ways. They then reviewed the effectiveness of each method. Hammond took on the topic of establishing a neutral zone in the OR. We needed to come up with a way as a reminder to the staff to incorporate this unfamiliar information and to make it familiar, she shares. The way that I did that was I included it in a place in the OR records where they have to answer what the neutral zone established. Therefore, the nurses and the techs and the physicians in the room have that as a reminder to help them to establish the neutral zone and if they are not able to do that, that they have at least set up some kind of communication technique while they are in the midst of handling or passing sharps.

Lexington also partners with its liability insurance provider, Palmetto Health Trust Risk Management Services and Healthcare Liability Insurance Provider (PHTS), to affect change. PHTS provided a physician consultant, Mark S. Davis, MD, FACOG, whose book Advanced Precautions for Todays OR was provided free of charge to the organization. This book was given to surgeons and staff, and new hires in the OR continue to receive a copy and are required to take a post-test.

Another initiative within this partnership was the inclusion of a physician champion in an effort to gain medical staff support and to assist with physician and staff education. The focus was toward the OR because of course the OR is the area in which most injuries occur because of the magnitude of the sharps that are being handled on a given day, Hammond says. So the physician champion would help on the medical side of the house to have them in the loop.

Hammond has also established a staff hero/ heroine award, which is an annual recognition for an individual who has done something to promote sharps safety initiatives in a way that has made some kind of impact. This years award will be presented in December which is Lexingtons Sharps Injury Prevention Month.

Comprehensive resource information also is made available on the health systems Lex- Loop intranet Web page. LexLoop features the hospitals house-wide sharps safety device catalog. By having this safety device catalog on the intranet, anyone can access and see what our safety devices are so if they have any question about it or if they see something unusual come across that maybe they didnt quite pick up on when we initially disseminated the information, it will be there, Hammond explains.

Many positive outcomes have been noted from the multifaceted sharps safety program at Lexington including an increase in injury reporting. By acknowledging and supporting what employee health is doing in our facility and also making the tool more user-friendly, the staff is more compliant in doing this, she asserts. Were not where we want to be yet with physician reporting, she adds, but notes they also are seeing more compliance among their physicians.

Hammond notes that keeping the awareness continuously going is what has helped their program to be successful. We accomplish this through so many mechanisms, she says. I found that partnering with NIOSH and PHTS helped substantiate and legitimize our efforts, and provided such wonderful resources and materials to assist with the cause.

Michelle Bushey, RN, BSN, CIC, took on the position of director of infection control at Bon Secours St. Francis Hospital in Greenville, S.C. just over a year ago. Since her arrival at Bon Secours she began an enhanced multidisciplinary sharps safety committee and it is affecting change.

We just changed our huber needle, she shares. The unit manager knew of our meetings and she wanted a different huber needle. She wanted a safety device. She came to us and we found out there was one available; we didnt know one was available.

Bushey says they have purchased safety goggles; all of the nurses now have their own pair. They also have show and tell. We found that being a big system, two hospitals with all sorts of different specialties, the units were all ordering different things, so at our April meeting we had show and tell and everybody brought in all of their devices. It was interesting because one ER (representative) said Oh my gosh, I didnt know you had that device here. I wanted to use that device. It was already in stock and already being ordered, but she didnt know it was available. So that was a way to sort of get everybody on the same page.

The committee also reviews any needlestick injuries as well as the devices from which they occurred. They then use that information to affect change by ensuring the implementation of either a safety device or a more safe device for that particular item. Were meeting our goals, she says. Our goal for this year was to reduce our needlestick injuries by 20 percent and we are right on track.

Gill points out that facilities can develop a safety culture and enhance open communication through the use of these committees, but she warns it does not come easy. Its taken a lot of years, she says. It takes a long time to gain not only the safety culture, but it takes a long time to gain staff trust. Staff realizes that I am in the prevention business. That is what we do here and we want communication going so we can prevent anything further from happening. Staff feeling like they are free to talk to us and report exposures, and help us out in prevention that has been accomplished here.

The key with safety is it has to be an ongoing process, Gill continues. You cannot let up, you have to involve your staff, there has to be ongoing communication. The prevention of occupational exposures has to be something that is ongoing, not forgotten, and brought up all the time. It cant just end with saying, 'Ive complied by bringing safety products into the facility.' I think we get comfortable sometimes. I think we get too complacent. Weve done our training and weve got our products in place and everybodys using them. Then, we kind of go stale again. You become complacent and it kind of goes away. This is something that cannot go away. This is something that wont go away. As long as there are sharp objects, as long as HCWs are at the bedside, this is something that we cannot let up on in healthcare. 

SHARPS DISPOSAL

The use of a sharps disposal service, such as Sure-Way Systems Inc., has benefi ted many facilities. Through reusable sharps container devices, which come in a variety of sizes, hospitals may be able to realize cost savings while eliminating a significant amount of waste, all while endeavoring to keep healthcare workers safe, according to Sure-Way. The service is also designed to aid compliance with American Hospital Association (AHA) and Environmental Protection Agency (EPA) waste stream reduction goals.

The company offers several options in terms of service and pricing, from full service, in which Sure-Way personnel collect disposal containers from their locations in the hospital, to dockside service, where healthcare workers handle the containers within the facility and bring them to a loading dock for pick up. Because sharps are transported to the companys treatment facility and disposed of there, the risk of needlestick injuries may be reduced with this type of service.