Infection Control Today - 06/2004: New Developments

New Developments in Primary Prevention and Sharps Safety

By Steve Bierman, MD, and Brad Poulos

While preventable medical-sharpsinjuries still occur at a disturbing rate, healthcare workers can feel heartenedby some positive events over the last several months. In particular, twovulnerable groups nurses and physicians-in-training are better protectedtoday because of recent developments in the regulatory area.

These developments include a new fact sheet on cathetersecurement from the Occupational Safety and Health Administration (OSHA), aswell as major new enforcement actions by OSHA against hospitals that violate itsBloodborne Pathogens Standard (BPS). The nonprofit National Alliance for PrimaryPrevention of Sharps Injuries (NAPPSI) has played an active role indisseminating information about these and other developments that affectinfection control professionals.

With an estimated 590,000-plus clinicians and other healthcareworkers (HCWs) victimized by accidental needlesticks every year, sharps safetycontinues to be an essential focus. OSHA plays the most prominent role in thisarea, either through the federal administration or through individual stateOSHAs. These agencies can fine hospitals and publicize their actions, either inresponse to anonymous HCW complaints about unsafe devices or, in many cases, asa result of unannounced inspections of workplaces such as hospitals.

Most recently, OSHA issued a new fact sheet in February 2004that clearly delineates the needlestick risk posed by catheter placement. Thefact sheet describes the potential advantages of using adhesive anchors, insteadof tape or suture, to secure catheters. This technology greatly reduces oreven eliminates needlestick risk related to catheter securement.

The OSHA fact sheet, titled Securing Medical Catheters,noted that all catheters for vascular access must be inserted with a needle. Therefore, inserting a catheter exposes the healthcareworker to the risk of a needlestick. This is the first time OSHA had sodirectly connected catheter placement and sharps injury risk. The fact sheetalso stated that adhesive anchors are a suitable alternative to tape orsuture, the traditional methods for securing catheters. In the case of suturesecurement, OSHA pointed out that adhesive anchors eliminate the direct injuryrisk posed by suture needles.

The fact sheet also stated that adhesive anchors can provideimproved catheter stability, thereby decreasing catheter migration,dislodgment, and the necessity of reinsertion with its associated needlestickrisk. In other words, adhesive anchors can do a better job of securing thaneither tape or suture, greatly reducing a second level of sharps injury risk:the needle exposures from unplanned catheter restarts. This, too, is newterritory for OSHA, which had not previously recognized the needlestick dangerfrom tape securement.

OSHA also played a central role in a major violation citationagainst a prominent New York City teaching hospital. In September 2003, OSHAfined Montefiore Medical Center $9,000 for multiple violations of the BPS. The violations included 26 instances of failure to usesafety-engineered devices. The case was initiated by a complaint filed byMontefiore medical residents. Its worth noting that the hospital, which hascontested OSHAs action, was not wholly or flagrantly noncompliant with theBPS. Rather, the hospital was fined because its needlestick-safety efforts wereinsufficient, not because they were wholly lacking.

Steve Cha, MD, chief resident in internal medicine atMontefiore, was the lead complainant against Montefiore. He told Advances inExposure Prevention, a publication of the International Healthcare WorkerSafety Center (University of Virginia): In terms of implementing safety,Montefiore has certainly made progress. [MMC] is probably pretty typical of manylarge teaching hospitals in that respect; its done a fairly good job withsafety. But I think the message here is that pretty good is not goodenough.

Primary prevention perceived a significant boost from OSHAsaction at Montefiore and the attention this action has received. Among thecustomary practices for which Montefiore was cited was the practice of suturing(and the attendant exposure to dangerous suture needles), when suturelessalternatives such as adhesive anchors are available, appropriate and feasible.

The message is also that hospitals dirty laundry may not bekept inhouse, if airing it helps protect healthcare workers. Cha joined SidneyWolfe, MD, director of Public Citizens Health Research Group; Lauren Oshman,MD, MPH, president of the American Medical Students Association, and others in signing a bluntly worded letterabout Montefiore to the president of the American Hospital Association (AHA).The letter started off by requesting that the AHA alert members to OSHAssanctions against Montefiore. The signers noted that conditions similar to thoseat Montefiore likely existed at other AHA institutions, puttingphysicians-intraining, nurses, and other hospital staff at risk and exposing theinstitutions to OSHA sanctions of their own.

But the real thrust of the letter came at the end: Ifhospitals failed to adopt available safe devices, medical students andresidents stand ready to file institution-by-institution complaints againstviolating hospitals. This position has strong support from NAPPSI.

To make sure their concerns were well-understood, Cha andPublic Citizen also published the letter he received from OSHA detailing thecomplaints against Montefiore and OSHAs response. The documents are available at www.citizen.org/publications/release.cfm?ID=7287. 

OSHAs actions in the Montefiore case suggest that theagency will no longer be content with partial efforts to comply with the BPS. Clearly, institutions will be targeted for action even if theyhave implemented some safety devices, as long as they continue to usetraditional devices in other areas where newer, safer alternatives areavailable.

Thats not the only red alert on the OSHA front. Two monthsprior to the Montefiore citation, OSHA slapped a Beaver Falls, Penn. nursinghome and its parent company with $92,500 in fines for BPS violations. The finesincluded $70,000, OSHAs maximum, for a willful failure to use safetydevices. The maximum penalty was unprecedented for a safety devices violation,another sign that OSHA is losing patience with institutions that ignore the BPS.

More Sharps-Safety News

Since last fall, several other developments have also helpedspread awareness about more effective sharps-safety approaches. Thesedevelopments include:

• A campaign to protect physicians-in-training from suture needlesticks. NAPPSI advocates a sharps-safety strategy called primaryprevention. Primary prevention employs an obvious logic: eliminate theneedle and eliminate the risk. Practices and technologies that eliminate medicalsharps should be used, wherever feasible to maximize healthcare workerssafety. This approach is superior to secondary prevention technologies that render sharps safer. Secondary prevention technologies sometimes fail, and can alsobe improperly deployed by negligent or poorly trained workers. NAPPSI also supports secondary prevention when primaryprevention is not appropriate. Among NAPPSIs membership are various professional nonprofitassociations, more than 20 medical device manufacturers, and more than 4,000individual clinicians.

• Last year, NAPPSI launched a campaign to protect medicalinterns and residents from accidental suture needlesticks. Protecting AmericasInterns and Residents from Sutureneedle Sticks (PAIRSS) is aimed at teachinghospitals. For training purposes, physiciansin- training are often asked toperform unnecessarily risky procedures such as suturing catheters, whensutureless alternatives are available. By raising awareness of primaryprevention, NAPPSI hopes to reduce the high rate of injuries that occur inteaching institutions. As part of the PAIRSS campaign, NAPPSI sent a letter to thepresident of the American Hospital Association expressing support for theposition of Montefiore Medical Centers residents. The letter also requestedthat AHA members be urged to adopt specific devices and techniques that preventsuture injuries. In addition, NAPPSI sent a letter to OSHA assistant secretaryJohn Henshaw commending the agencys action in the Montefiore case andexplaining the primary prevention strategy. NAPPSIs sharps-safety campaignfor medical residents has been covered by a number of media outlets, includingAmerican Medical News, a publication of the American Medical Association.

• The Association of Occupational Health Professionals inHealthcare (AOHP), a NAPPSI member, formed an alliance with OSHA in February2004 to protect employees health and safety. Among its primary concerns, thealliance tries to reduce HCWs exposure to hazards associated with patienthandling and bloodborne diseases.The alliance also focuses on the implementationof best practices and technologies at healthcare facilities. As part of thealliances efforts to promote safer working conditions in the healthcareindustry, it is training each organizations professionals in jointlydetermined best practices and effective approaches.

• Earlier this year, NAPPSI and AHOP published results of apreliminary but significant survey on sharps injury risk to medical students,interns, residents, and fellows. The results were described in an article byAOHP president emeritus MaryAnn Gruden, CRNP, MSN, NP-C, COHN-S/CM, and NAPPSIpresident Steve Bierman, MD, in the February 2004 issue of AOHP Journal. Onenotable result of the survey concerned curved suture needles.

The survey showed that manual manipulation of suture needlescaused a much larger proportion of reported injuries (33 percent) than any otherroot cause. That in itself was not surprising. A published analysis of 2,111percutaneous injuries in a teaching hospital had found that a similar percentage(35 percent) of injuries to interns and residents were caused by suture needles.However, the new survey also found that the overwhelming number (91 percent) ofsuture needlesticks was caused by curved suture needles, which many physiciansmistakenly believe to be effective safety devices. The survey results furtherunderlined the wisdom of primary prevention. Accidents can still occur with safersharps such as curved suture needles. Clinicians would be much betterprotected if they were provided sutureless technologies and were trained intheir use. Among other important statements, the authors also noted thathospitals group purchasing contracts for bulk discounts are problematical, iftheir supplier doesnt stock sharps-safety devices. The authors recommendedthat such institutions develop more flexible purchasing arrangements to protecttheir workers, if certain appropriate safety devices are not available oncontract.

Safer Days Ahead?

Although the solutions to the sharps safety problem seemfrustratingly obvious to those of us who work closely with the issue, gettinginstitutions and personnel to adopt new habits and technologies is always anuphill climb. But the pace of change can really speed up once a threshold isreached. The Montefiore situation and the issuance of the OSHA fact sheet aremajor developments, and the other events just discussed add to the momentum.Widespread sharps safety may be reaching a tipping point, where the adoption andstandard use of the best safety devices truly becomes standard operatingprocedure, as required by law.

Steve Bierman, MD, is president of NAPPSI and Brad Poulos isNAPPSIs executive director. NAPPSI membership is free to individual clinicians andnon-profit organizations. Visit www.nappsi.org or call (858) 350-8623.