Infection Control Today - 05/2004: In the Name of Safety

In the Name of Safety
Building a Bloddborne Pathogens Program

By John Roark

Education, vigilance and a culture of safety help create a secure environmentfor healthcare workers and patients.

There are two classes of blood and body fluid exposures:mucocutaneous (exposure of the eyes, nose, or mouth as a result of splashes,spray, or direct contact) and percutaneous (needlestick and sharp objectinjuries to the skin). Mucocutaneous and percutaneous exposures have differentpathogen transmission rates and require different prevention methods. Of thetwo, percutaneous exposures are the most common occupational injury as well as the most commontype of bloodborne pathogen exposure among healthcare workers.¹

Occupational exposure to bloodborne pathogens from needlestickinjuries and other sharps injuries is a serious problem but is oftenpreventable, says the Centers for Disease Control and Prevention (CDC), whichestimates that each year 385,000 needlesticks and other sharpsrelated injuries are sustained by hospital-based healthcarepersonnel.²

Although standard precautions were introduced in the 1990s,research continues to report less than 100 percent compliance among healthcareprofessionals with measures demonstrated to decrease disease transmission.

In my opinion, the biggest challenge is in the reportingand follow-up of the exposed healthcare worker whether by needlestick injury ormucous membrane or non-intact skin exposure, says Elizabeth F. Chinnes, RN, BSN, CIC, infection control consultant, ICSolutions. In many facilities in which I have worked or consulted, large andsmall, there is not a good system to handle reporting and follow-up ofbloodborne exposures. Often times, the employee is to report to employee healthoffice during normal business hours and another site during evenings, nights,and holidays. The process is often hindered by the employee sitting for hours inthe ER its not considered a true emergency when in fact, it is oreven being sent off site for follow-up.

In addition, the more complex our procedures are, the moredifficult reporting is to enforce. There are many areas for the incident to slipbetween the cracks in the modern healthcare system. For example, somefacilities, and even physicians, do not order the appropriate bloodwork on thesource from whom the employee was stuck and/or on the employee. This in turndelays our actions and causes us to have to retest the blood sample for theappropriate tests for bloodborne pathogens.

Old Dogs, New Tricks

Nurses are trained well in nursing school, says Terry JoGile, MT, (ASCP) MA Ed, president of Gile and Associates, a consulting firm thatspecializes in keeping work environments accident-free. They enter the fieldand another nurse who has been there for 30 years says, Let me show you ashortcut. Its always worked, Ive never stuck myself. All of thewonderful training that theyve received goes down the tubes. Thats one ofthe challenges the more experienced employees using time-honored shortcutsthat circumvent the safety issue.

Deeply ingrained behavioral patterns are an obstacle, andalthough change is constant, getting healthcare workers to change their habitsand think safety-smart doesnt happen overnight. It is important to note thatthe Occupational Safety and Health Administration (OSHA) can hold a facilityaccountable and can issue citations and fines if safety practices are notfollowed.

I think that behavioral change is a big challenge, saysKeith Kaye, MD, MPH, associate professor of infectious diseases at DukeUniversity.

Healthcare workers are often resistant to changes and newdevices, but if you can teach them how to use new devices, they will eventuallyaccept them. Often you have to switch out old products; you have to beaggressive about it if you keep the old product, people will still use it.

What Works?

An effective bloodborne pathogens prevention program includesseveral fundamental components that must work in concert to protect healthcareworkers from exposure. Policies and procedures that promote a culture of safetyhave a trickle-down effect on acceptance and adherence to engineering controls,safe work practices and personal protective equipment (PPE).

In healthcare, there has traditionally been a hierarchy interms of a from-the-top-down approach, says Michael Tapper, MD, anepidemiologist at Lenox Hill Hospital, New York, and past president of theSociety for Healthcare Epidemiology of America, Inc. (SHEA). Healthcare, formany people in lower socioeconomic levels, is entry level to the workforce. If you look at the people who are at the lowest levels ofhealthcare many of them are non-American born. For many of them, this is thebeginning of the American dream. At the same time, theyre often lesswell-educated than U.S.-trained people, theyre less well educated than theaverage trained physician or nurse, theyre more easily intimidated, lesslikely to demand certain levels of protection. Or theyre more likely, if thatprotection is not there, to be intimidated into doing their job anyway.

Organizations with strong safety cultures consistently reportfewer injuries than organizations with weak safety cultures. This happens notonly because the workplace has well-developed and effective safety programs, butalso because management, through these programs, sends cues to employees about the organizations commitment tosafety.⁴ Workers are more likely to report if a well established andknown plan is in place. This requires constant education and reminders such asposters throughout the facility, updates in orientation for new staff and yearlyreviews and newsletters.

Simplify your process, delete unnecessary steps, saysChinnes. If possible, have packets put together which lead thehealthcare worker or supervisor in a step-by-step fashion through the steps tofollow if they receive a bloodborne exposure even to the point of lab slipswhich are filled out for bloodwork on the source and the employee. Ensure thatnew safety devices are inserviced on all shifts and in all departments wherethey will be used. Dont forget that education is not a one-step process.Particularly if there is a problem with a new device, the staff may need moreeducation and reinforcement periodically. We each need to assume personalresponsibility to make our workplaces safer and even look at near missesto determine what we could have done differently.

Defense, Not Offense

The first line of defense is a prepared healthcare worker whounderstands the risks and takes the proper precautions, says Tapper. In the hierarchy for sharps injury prevention, the toppriority is to eliminate or reduce the use of sharps where possible. Next is toisolate the hazard, thereby protecting an otherwise exposed sharp, through theuse of an engineering control such as self-sheathing needles and needlelessdevices. When these strategies are not available or will not provide totalprotection, the focus shifts to work practice controls and personal protectiveequipment (PPE).

Engineering Controls

Engineering controls eliminate or isolate a hazard in theworkplace. The emphasis on engineering controls has lead to the development ofmany devices with injury prevention features. Safety devices on needles havegreatly reduced needlestick injuries.

The most important safety devices that have come out arethe safeties that go over the needles that we are using on a routine basis,says Peggy Gutman, RN, BSN, COHN-S, director, occupational health services,Childrens Memorial Hospital, Chicago. The changes in the safety devicesover the last three years have been dramatic. Theres practically no sharpinstrument out there that you dont have an option to buy with a safety deviceon it. Those are really helping to reduce some of the injuries.

But, Gutman points out; all the safety devices in the worldcan not eliminate accidental exposures that are going to occur.

I find that my biggest challenge is accidental injuries,particularly those that occur in situations where you have very limited time theyre not thinking about safety, theyre focusing on an emergency, shesays.

Tapper agrees. Everyone will tell you that they practicegreat infection control, but when the ER is jammed with people, things seem toget more difficult. When the ICU and nursing unit are well-staffed, things gorelatively well. As soon as things get hectic, as soon as people get busy, assoon as theres a bigger patient volume than you can easily demand, things geta little sloppy at all levels of infection control. And I think thatsgenerally true in terms of bloodborne pathogen protection as well.

When people are stressed, when people get busy, thats whenaccidents are going to happen. The other problem this creates forpost-exposure is that it delays the time that the individual actually reportsthe incident, says Gutman. In a high-risk situation, theyre going to takecare of the trauma first and report the injury later, which means that thatinoculation is in their system for a longer period of time before you have anykind of opportunity to do any preventive treatment. If we do need to giveprophylactic medications, ideally, we attempt to do that within 24 hours.

No single safety device or strategy will serve as a panacea,or have the same efficacy in every facility. Employers must develop their ownprograms to select the most appropriate instruments for their specific settings.

The key to successful prevention, says Peg Luebbert, MS, MT(ASCP), CIC, system consultant for infection control, Alegent Health, is auser-friendly sharp in the hands of an educated user. If youve got theright sharp and youve educated the staff on how to use it, theyll use it.You can have a lousy sharp and you can educate and educate. But if that sharp isnot user friendly, theyre not going to use it, and vice versa. You can havethe best sharp in the world, but if they dont know how to use it, they wont.

One hindrance to the widespread use of some safety devices iscost. Spring-loaded syringes which automatically retract the needleinto the barrel of the syringe may have a greater degree of safety thantriggered devices, but are cost-prohibitive.

It all comes back to cost, says Tapper. Yes, you canengineer a better safety syringe. Yes, you can engineer all kinds of devices.But many of these safer devices are considerably more expensive. The industrycontinues to move toward safety, but safety still comes at a very high pricewhen theres very little fat left to squeeze it from someplace else.

We also have to be careful as we introduce safety devicesto make sure that the purpose which is to not only protect the worker, butto protect the patient is being looked at, he continues. In the rushto get them on the market, some safety devices of have not been as carefullystudied, and some of them may have down sides in terms of patient care.

Safe Work Practice Controls

Work practice controls changing the way in which a task isperformed is an important component to preventing bloodborne pathogenexposures. Due to the high frequency of blood contact and percutaneous injuries,body substance exposures are even greater among personnel working in the OR.Surgery requires the use of sharp instruments, sutures with needles, and speed,which add up to a hazardous work environment. Reducing the risk of sharpsinjuries, particularly in the OR, can be facilitated by implementing saferpractices, such as announcing that a scalpel or other sharp instrument will bepassed, the use of a neutral zone in which sharps may be placed and retrieved(to reduce hand-to-hand transfer) and never tying sutures with the needle inhand.

Having an effective disposal system in place for used sharpsis an important work practice control. Sharps disposal boxes should accommodatevarying sizes of needles, should be conveniently located and readily accessible.

If disposal boxes are on the nurses medication cart, butthat cart is way down the hall, chances are someone is not going to run down thehall to dispose of a sharp. Theyve got to be available at every point of use,says Tapper. Youve got to make sure of subtle things that sharpsdisposal boxes are mounted at eye level, where everybody can see whatsinside. If youre standing up looking down into the sharps disposal box, yourenot likely to stick yourself because you can see the contents.

But if youre a nurse whos five feet tall and the box isconveniently mounted so that taller people can see down into it, you have toreach up with your hand. Imagine putting your hand into the basket and youreally cant see where your hand is going. You could drop something in and getstuck with a needle. If there are 60 empty syringes with needles, whose needlewas it? Did it come from a patient with HIV, or was it a clean needle that wasdropped in there?

One of the things that worked very well for us was to do awalkaround inventory of where our safety disposal devices were, how they weremounted, what wasnt mounted and secured, how many feet were people having towalk from the point of use to disposal says Gutman. A lot of our needlestickswere happening at the point of disposal. A good sharps container program andideal mounting location is really important. OSHA does provide guidelines, but Ithink many times they are overlooked because there are so many things that gointo a patient room so many things on the wall. The containers have alsobeen greatly improved thanks to the manufacturers, and its very difficult toaccess a box and get hurt.

Again, Tapper references the hospital pecking order. Youvegot to make sure someone empties [the disposal box]. Remember that hospitals arehierarchical. The people who usually get laid off first are the housekeepingpeople the lowest people on the totem pole, sometimes not entirely protectedby union contract. If they go, then who empties it?

Personal Protective Equipment

The final line of defense is personal protective equipment.This level is meant to supplement engineering and work practice controls ifthe first two controls cannot eliminate a problem, the third can mitigate itseffects. In the OR, gloves, gowns, masks, and protective eye wear areexamples of this third level of control.

You have to evaluate every task that you perform thatinvolves blood and body fluids to determine what kind of exposure youre goingto have, says Gile. Can an engineering control be put into place sothat the stick/splash/spray can be completely avoided?

Surgical masks and goggles are the two of the most commonlyused pieces of personal protective equipment. Masks are worn for surgicalasepsis and to prevent contamination of the mucous membranes of the nose andmouth of the person wearing the mask. The use of face shields is less common.

While not as prevalent as percutaneous exposure, mucocutaneousexposures are nonetheless of significance, and PPE is a sentinel means ofdefense. Protecting the eyes, nose and mouth from direct contact with possiblycontaminated body fluids presupposes the use of masks and shields readilyavailable and consistently employed.

Nobody wants to get splashed with blood thats Hep B- orC-positive in their eyes or in their mouth, says Tapper. Weve had someengineering controls to deal with that. Thats one of the things that you tryto do you look at procedures and ask, is there a safer way to do this? Do Ihave to do it just because its always been done this way?

Until recently, gloves have been worn primarily to maintainsterility of the surgical wound. Glove use for protection of OR personnel is anextension of that practice. Standard precautions require that gloves be wornwhenever there may be contact with blood and body fluids, when touching mucousmembranes and nonintact skin, when handling contaminated instruments, and whenperforming venipuncture or other vascular and arterial access procedures.Unfortunately, faulty surgical gloves have been all too common, although it is believed that the quality of glovesis improving.⁵

Using PPE is where we sometimes see a lot of downfall,especially eye protection, says Gutman. I think that eye protection isjust not a natural thing. Weve gotten used to using gloves in healthcare.Even before bloodborne pathogens, gloves were there and we used them for somethings. After bloodborne pathogens became a very significant concern, there wasa lot of gloving. But no one expects or plans for a splash. They overlook the fact that they might need that protectionwhen they go in to start a procedure, or do something where they couldpotentially be exposed to a splash. Thats a real challenge. Its anopportunity for us to provide creative education.

Gloves, gowns, shoe covers, and caps have been worn tomaintain asepsis. Safety recommendations for the use of these items have beenaimed at preventing blood or body fluids from contact with health care workersskin and underclothing. Gowns vary in their ability to resist liquid penetration.⁴

It is important to note that although PPE provides a barrierto shield skin and mucous membranes from contact with potentially infectiousbody fluids, most protective equipment can easily be penetrated by needles.

A Changing Culture

Healthcare workers are increasingly demanding that theyshould have the same level of protection that other people have, and that justbecause youre a healthcare worker doesnt mean that youre willing to undergo risks to your own health, says Tapper. Theconsequence is not just for you, but for your spouse, your kids. The culture ischanging, Im not sure that across the board the quality of the services isreally there to the same extent that we would hope it would be at this point. Alot of thats driven by finances. I think that these are all things thatpeople would do if the money were there.

Luebbert sees practicing safety as a means of far-reachingimpact for healthcare workers. The role of infection control and safety isnot so much to do infection control, but to be there in their face, to betheir conscience. To reinforce, I need to take care of myself. I need toprotect myself. I need to worry about taking things home to my family as much asI am protecting the patient.

Looking ahead, Gutman believes that teamwork can have asignificant impact on effective bloodborne pathogen safety.

Are we ready now to start saying lets do something as agroup to focus our energy on looking at each other and how were doing thesethings? Before you can do that you have to create a culture of collaborativeapproach to solving problems. I think that people from the outside look at us asa healthcare team more than we start out that way internally. Weve madea very concentrated effort for a number of years on culture change. As theconcept of teamwork becomes integrated and becomes the way of doing all things,I think the opportunity is there in terms of sharp safety to use that sameconcept of peer review and collaborative approach to solving the problem. Weshould be able to go back and say, Look, youre falling out of range withother areas inhouse, heres what seems to be happening and these are thestatistics, what do you think the problems are? Give them the opportunity totake charge and take control. If they can be responsible for problem solvingwithin their own areas, then well work around some of these emergent actionsthat are now the roadblock.

I really think thats where our future is. Weve gottenabout as far as we can with adding the safety devices. The manufacturers willtweak and improve things a little bit, but most of the products have now beentouched on and the redesign is there. Affordability will get better and better.I think now were on to that more difficult approach: just how do you getpeople to do the right thing all the time? Thats the future.