Infection Control Today - 07/2002: Success Story

Sticking It to Us: Implementing Sharps-Injury Interventions

By Jenae Schlipman, BSN, RN, MBA/HA

TheNeedlestick Safety and Prevention Act (NSPA) was signed into law Nov. 6, 2000.This act guided the Occupational Safety and Health Administration (OSHA) to makerevisions to its Bloodborne Pathogen Standard, published Jan. 18, 2001, takingeffect April 18, 2001. A grace period was implemented to allow outreach andeducation to take place for both OSHA personnel and the public, so the act wasnot enforced until July 17, 2001.¹

The requirement for healthcare facilities to adopt safety devices andengineering controls was not new to this legislation, since the requirement hasbeen in effect since 1992. New requirements force healthcare facilities todocument the input solicited from non-managerial staff in identifying,selecting, evaluating and implementing these safer devices, and to maintain asharps injury log for recording exposures.

What are "Engineering Controls?"

The revised Bloodborne Pathogen Standard of 2001 defines engineering controlsas "controls (e.g., sharps disposal containers, self-sheathing needles,safer medical devices such as sharps with engineered sharps injury protections,and needleless systems) that isolate or remove the bloodborne pathogen (BBP)hazard from the workplace."¹

It is up to each employer to search the industry for these engineeringcontrols, as OSHA does not provide a list of new safety products available ormake recommendations regarding the usage of these safer products.

What if Alternatives are Not Available?

If a safety device is not available in the market to replace a specificdevice, we are not required to convert those nonsafety products to includesafety features. We are, however, required to continually investigate new safetydevice alternatives at least annually for each device, documenting our ongoingefforts to convert any nonsafety sharps to include safety features.

Which Healthcare Facilities are Addressed?

Any facility falling under OSHA and having employees with occupationalexposure to BBPs is required to comply with this federal law, regardless of thenumber of employees. There is a documentation exception for employers with 10 orfewer employees. These employers are not required to maintain a sharps injurylog, and OSHA record-keeping requirements do not apply. However, they must stillprovide safety devices for their staff and adhere to the other OSHA BloodbornePathogen Standard requirements.²

Our Story

One of the first things we did at The Children's Hospital (TCH) in Denver wasto evaluate our BBP exposures from January to October 2001 to identify areaswhere frequent exposures occurred and identify specific devices involved inthese exposures. Based on the exposure summary for this period, ourhigh-priority devices included:

• Sharp instruments, including sutures, blades and knives

• Intravenous (IV) catheters

• Lack of personal protective equipment (PPE)

• Hypodermic needles

In a national sharps injury report, the Centers for Disease Control andPrevention (CDC) reported, "Up to 86 percent of needlestick injuries can beprevented by using safety-engineered needles and other devices." Accordingto data collected from 55 hospitals by EPINet in 1997, the four most frequentsharps injuries involved the following types of blood-filled needles: butterflyneedles, phlebotomy needles, syringes and IV catheter stylets. In addition, theinjuries reported occurred 28 percent of the time during use and 22 percent ofthe time after use and before disposal.³

After identifying which devices to target first, we conducted researched tofind the best safety device products available. Our hospital held an OSHA fairDec. 3, 2001. Vendors offered hands-on demonstrations of safety products. Thisfair heightened awareness of new safety devices and provide informationregarding the requirements of the NSPA for our staff.

Trials were conducted throughout the hospital and various clinics testedselected safety devices. Trials were placed in locations based on specific areasof expertise related to each product. Selected trials included participation ofphysicians and nurses, with nursing staff participating in all of the clinicaltrials. Participants were asked to complete written evaluations fordocumentation purposes, and not all safety devices and products were found toprovide a safer option. Our decisions were determined by staff evaluations.

After adequate trials of each safety device, evaluations were summarized anddecisions to implement various safety products were approved by our hospital'sproduct evaluation committee (PEC) and OSHA council.

In-services were scheduled in January and February to provide staff withhands-on training. Staff members were encouraged to attend and sign-in sheetswere kept for each department. The medical residents were trained at aconference in March.

After in-service training was completed, the materials management departmentmade the appropriate changes for distribution of these products. OMNI cells andC-lockers were automatically switched out in both in-patient units and clinics,removing nonsafety items and replacing those items with the appropriate safetydevices. In addition, a memo was sent to all TCH medical staff providingspecific information surrounding the process of converting to these safetydevices. This memo also was posted on the TCH Intranet.

The NSPA requires ongoing selection, evaluation, implementation and educationof new safety devices as they become available. A safety device committee wasformed, with representation from nearly every specialty to help evaluate newsafety devices, and it reported monthly to the PEC.

Costs to convert to safety devices are steep. While additional costs relatedto conversion are incurred through products and training, there will hopefullybe a decrease in the number of exposures and costs related to needlestickinjuries.

The U.S. General Accounting Office (GAO) conducted an analysis of costssurrounding the implementation of safety devices.⁴ The analysisfocused on healthcare workers (HCWs) in hospital settings, representingapproximately 40 percent of HCWs nationally. The CDC estimates that 384,000percutaneous injuries occur annually in hospitals. It is estimated that 69,000needlesticks in hospitals can be prevented in one year by using needles withsafety devices. This reduction may prevent at least 25 new cases of hepatitis Bvirus (HBV) infection and at least 16 new cases of hepatitis C virus (HCV)infection per year. An additional estimated 51,000 needlesticks could beprevented each year by using safer work practices such as:

• Creating appropriate locations for sharps containers

• Maintaining appropriate fill levels in sharps containers

• Not recapping needles

• Proper disposal of needles in sharps containers

Needles with engineered safety features are more expensive than conventionalneedles. The GAO projects that the annual cost increase in these expenses forhospitals will be between $70 million and $352 million. These estimates do notinclude costs such as training or time employees spend throughout the learningcurve of introducing new products into their practice.⁴

We conducted a cost comparison of new safety products implemented at TCH.Data was gathered on safety device usage from a high-acuity inpatient unit atour facility. The data showed a cost increase of $1,150 to implement new safetydevices in this unit.

The primary objective of the NSPA is reducing needlestick injuries. Theaforementioned cost increases may be softened when applying the costs saved fromfewer needlestick injuries per year. Published estimates of costs associatedwith needlestick injuries range from $500 to $3,000 per injury. Given that thereduction of needlesticks in hospitals is expected to be 69,000, hospitals willsee a savings in post-exposure treatment costs of approximately $34.5 million to$207 million each year.⁴

The bottom line is that only those hospitals experiencing high-cost scenariosfor post-exposure treatment will experience benefits exceeding costs whenimplementing safety-engineered devices. However, there is no price tag to showthe savings for preventing just one staff member from experiencing the emotionalstress of a needlestick injury, let alone the costs of a serologic testconversion.

BBP exposure rates are monitored very closely at TCH. Each month thefollowing are tracked surrounding BBP exposures:

• Number of exposures reported

• Specific type of device involved in the exposure

• If a safety version of the device used was available

• How the exposure occurred

• If the injury was preventable

Implementation of these new safety devices was completed in February. We hopethe number of BBP exposures will continue to decrease as staff use more safetyproducts and gain familiarity with them.

Jenae Schlipman, BSN, RN, MBA/HA, has served as a pediatric oncology nursefor four years. She will begin a one-year administrative fellowship at MiamiChildren's Hospital this month.