Infection Control Today - 07/2003: Getting the Point of Sharps Safety

Getting the Point of Sharps Safety:
Veterans Administration San Diego HealthcareSystem Wins 2003 NAPPSI and ICT Primary Prevention Safety Award

By Brad Poulos

The Primary Prevention Safety Award is sponsoredby the National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI)and Infection Control Today. The award recognizes a healthcare facilitythat has demonstrated efforts to prevent sharps injuries and champion primaryprevention techniques and technologies.

Since 1982 the Veterans Administration San DiegoHealthcare System (VASDHS) has been using a variety of sharps safety productshousewide with a particular focus on using primary prevention technologies(i.e., eliminate the needleeliminate the risk.) The depth and breadth ofactions to minimize sharps injuries at this facility demonstrate an extremelyproactive and effective sharps-injury reduction program that focuses not only onhealthcare worker (HCW) safety, but also patient safety, improved productivityand demonstrated cost savings.

The facility prides itself in setting thestandard of care for the community in sharps injury reduction products andprograms. Clinicians are strongly encouraged to bring to the administration anyand all safety products, ideas or suggestions that will help reduce anyremaining sharps injuries. The facility has a standing safety products committeethat meets monthly to review sharps-injury reports and statistics, conduct rootcause analysis and continually look for improvements in sharps safety.

The culture to minimize sharps injuries goesbeyond the frontline HCWs. Outstanding educational efforts include not onlyfrontline HCWs, but also downstream non-users in the housekeeping and dietarydepartments.

Because of its affiliation with the University ofCalifornia at San Diego Medical School, there is close interaction with the deanof student affairs to require all medical students, interns and residents tocomplete a sharps safety workshop before entering the hospital. Innovativeprograms include a 24-hour Needlestick Hotline for employees who sustain asharps injury to call for consultation; a 1st Dose anti-retroviral HIV kitto be used immediately after a high-risk injury; bi-weekly safety committeedepartmental internal rounds allowing coverage of the entire facility twice eachyear; and a proactive approach at full implementation of all safety productswherever possible.

In addition to carrying sharps-injury protectionto the staff within their own local healthcare system, VASDHS is part of theVeterans Integrated Service Network (VISN 22), a VA network of five hospitalsand 30 community-based clinics. The VASDHS takes a lead role at VISN meetings toshare sharps-injury reduction programs, thereby impacting thousands ofclinicians within the network.

VASDHS has 238 hospital beds, including skillednursing beds, and operates several regional referral programs includingcardiovascular surgery and spinal cord injury. It is affiliated with theUniversity of California, San Diego School of Medicine and provides training for809 medical interns, residents and fellows, as well as 64 other teachingaffiliations for nursing, pharmacy, dental and dietetics.

VASDHS has one of the largest research programsin the VA nationally, with a budget of more than $47.2 million (FY 2002), 220principal investigators and more than 965 projects. VASDHS is also home toseveral specialty research programs including Health Sciences Research andDevelopment (HSR&D), Mental Illness Rehabilitation, Education, and ClinicalCenters (MIRECC), the Research Center for AIDS and HIV, and the San Diego Centerfor Patient Safety.

As noted, VASDHS is part of the VeteransAdministrations Pacific Healthcare Network (VISN 22), which is comprised offive hospitals, 30 community-based clinics, 690 physicians, 1,700 registerednurses and 9,500 full-time equivalent employees. The five VA hospitals in thisnetwork are located in Los Angeles, Long Beach, and Loma Linda, Calif. and Las Vegas. Combined, the network hospitalsoperate 1,905 beds including 917 acute, 639 nursing home, 321 domiciliary and 30psychiatric residential beds. More than 700 medical residents and thousands ofnursing and allied health students are trained in network facilities each year.

The primary prevention technologies implementedinclude: sutureless catheter securement products, needlefree access valves,pulse oximeters, surgical glues in dermatology, needleless IV products,needleless drug delivery products, needleless hemodynamic monitoring, prefilledsyringes and plastic blood collection tubes.

Using primary prevention technologies whereverpossible is a constant goal at this facility. Even before the passage of theNeedlestick Prevention Act of 2000, the materials management group immediatelyrecognized the value of using catheter securement devices as a way to not onlyreduce sharps injuries from suture needles and IV stylets, but to also improvepatient safety, improve healthcare workers productivity, and reduce costs.The use of StatLock® IV catheter securement devices, packaged with the Alaris®Smartsite Needlefree System, provides an example of combining two primaryprevention technologies, along with the use of a secondary prevention technology(a safety IV catheter: J&J ProtectIV®) to maximize HCW safety. Thisforwardthinking approach was recognized in 1999 by a local television station ina feature focusing on improving healthcare delivery in the community.

Wisely, by analyzing the cost of a needlestickinjury, versus the increased cost of a safety device, this VA system decided itwas less expensive to prevent the needlestick injuries than to treat them.

Secondary prevention technologies implementedinclude: safety IV catheters, safety syringes, safety blood collection devices,safety lancets, safety scalpels and safety biopsy needles.

As long ago as 1982, the VASDHS analyzed wherethe most frequent needlesticks were occurring. Blood Glucose tests needles werethe number one source. They then evaluated three different safety products.After evaluation, they selected one device and converted 100 percent of theblood glucose test needles to the safety product. In the first year followingimplementation the VASDHS saw a reduction of 22 needlesticks, or approximately80 percent.

Training and education to prevent sharps injuriesbegins with all new employees. In using safety devices, the clinician not onlyneeds to know how to use the device, but also must have a competency with thedevice. Recognizing this, all new nursing education classes include practicesessions to make each nurse comfortable and competent with the new products.

The VASDHS is a teaching hospital, withresidents, interns and medical students rotating through. Before any medicalstudent, resident or intern is allowed into the hospital, they must attend aneedlestick safety workshop that instructs them on policies and productsavailable. They also learn policies and procedures on reporting needlestickinjuries. The medical students are also required to attend an infection controlorientation prior to coming onto the hospital grounds. This type of educationalapproach is the unique result of collaboration between the dean of studentaffairs at the medical school and the VASDHS infection control practitioner.

In the ICU, there is a product board with all thesutureless securement products displayed so as to educate the staff on whatspecific products are available to replace sutures.

Even before the passage of the NeedlestickPrevention Act of 2000, this facility was an early adopter of many new sharpsinjury prevention technologies. Eliminating sharps injuries wherever possible isa constant theme at VASDHS. There is a monthly review of all reportedneedlestick injuries within the safety committee to conduct a root causeanalysis and looking for methods for performance improvements (i.e., preventionanalysis). Any performance improvements are then conveyed to all applicablestaff meetings to prevent further occurrences. Members on the safety committeeinclude clinical staff from high-risk areas (OR, ICU, PACU, outpatient) as wellas infection control, employee health and materials management.

As an example of their commitment to employeeinvolvement with sharps injury prevention, when the hospital was puzzling overwhere to put sharps disposal containers, they asked for the staff to tell themwhere they felt the best locations were. To determine the height of thecontainers, they had the shortest nurse set the height, so as to accommodate theshortest staff members. This is an excellent example of involving the front lineHCWs.

The concern for downstream injuries(non-users) is paramount at this hospital. An example is in the dietarydepartment where sharps injury risk can come from sharps left on dining trays orplates. The VASDHS has put sharps containers in the dietary areas. They alsotrained the dietary staff on how to properly pick up napkins so as to avoid asharps injury, should there be a sharp under the napkin. Further, they trainedthe dietary staff to report any exposed sharps on the dining trays immediatelyto the staff nurse, who could then track down who left the sharp exposed. Thissame training was applied to the housekeeping and laundry staff.

The VASDHS has an annual sharps safety fair andtraining for the medical as well as the animal research staff connected with theuniversity and hospital.

The VASDHS operates a Needlestick Hotline,staffed 24/7 for employees who get a needlestick injury. The hospital infectiousdisease doctor is also on call 24 hours a day for counseling on high-riskneedlestick injuries. As mentioned above, the VASDHS has created its own firstdose kits. These are used in the ER, homecare and satellite offices and offeranti-retroviral medications for prophylactic treatment of HIV, post needlestickinjuries.

The safety committee routinely (twice a month,covering every department twice a year) does internal rounds to identify sharpssafety improvement areas. A recent example was the identification of overfilledsharps containers. This observation resulted in a policy change as to thechanging frequency of the containers, including designating who and when,calling for a clear delegation of responsibility.

The NAPPSI Clinician Advisory calls uponclinicians to employ both primary and secondary prevention measures to maximizesharps injury protection in the healthcare workplace. Clearly, the VASDHS hastaken the spirit of the advisory to heart. The implemented and reinforcedprimary prevention strategies were adopted long before they became mandatoryunder federal law. As a result, thousands and thousands of sharps have been keptout of the VASDHS workplace. And countless sharps injuries have doubtless beenprevented.

The secondary prevention strategies have renderedwhat sharps the VASDHS must employ safer. The constant staff input and staffeducation has created a safety environment at the VASDHS that is second to none.

Congratulations to the Veterans Administration atSan Diego Health System for their wise and widespread implementation of sharpsinjury prevention. Clearly, the VASDHS has earned the first-ever PrimaryPrevention Sharps Safety Award.

Brad Poulos is deputy director of the NationalAlliance for the Primary Prevention of Sharps Injuries (NAPPSI).

Education, Policy, Prevention: Employee HealthTeam Protects Workers from Needlesticks

By Kelli M. Donley

University Health Care System in Augusta, Ga.,was ahead of the curve when hospital administrators began pushing for safetydevices in the early 1990s. Today, employee health manager Rosemary Dudley, RN,says this insight gave her team an edge to protect their 3,500 employees fromneedlesticks.

We used posters showing actual pictures ofpeople who were involved in injuries, Dudley says, describing the systemseducation methods. The posters showed the three steps (employees should takeafter a possible needlestick) and we put them in areas where the workers are.That is what raised their awareness.

This three-step approach written in Universityspolicy includes immediately notifying a supervisor when potentially stuck by aneedle, cleaning the wound site properly and contacting employee health.

We also have educational videos house-wide andfor management, she says. We started on these right before the law cameout.

We knew it was coming. We stay on the cuttingedge. We dont want to backtrack; we try to do the right thing from theget-go. We really started in the early 1990s with needleless tubing andneedleless access.

The healthcare systems proactive approach toeducation, new product installation and policy-making has significantly reducedthe number of needlesticks and garnered national attention. University wasselected as the 2003 runner-up in the Primary Prevention Sharps Safety Awardsponsored by the National Alliance of the Primary Prevention of Sharps Injuries(NAPPSI) and Infection Control Today.

Dudley says one element of the healthcare systemsapproach to protecting employees includes piloting new products. In 1999,employees participated in a trial study of Premiers Safety Glide Needle.Dudley says such opportunities give healthcare workers the opportunity to voicetheir opinions about new products, which in turn motivates the manufacturer tocontinue brainstorming for even safer technologies.

New products are continually getting betterand better, she says. We do have challenges in training. At largehospitals, when a new device comes in, the first thing you do is you look at theproduct. Then you pilot it on the different floors where you think it may work.When you pilot it, the frontline workers decide if it is going to work and theygive you great input you can take back to the manufacturers. Then theyll comeback with something even better.

Some devices the system has piloted and usedinclude: Interlink Needless IV Access System, Johnson and Johnson Protectiv IVAccess, Vacutainer Safety-Lok blood collection, disposable retractable safetyscalpels, blood transfer devices, blood culture collection adapters and inserts,filter straws and blunt 18-gauge fill needles. The systems decision to pilotnew safety products, Dudley says, are in part responsible to the significantdecrease in employee needlesticks. Data provided by University shows 103reported needlesticks in 1997 in comparison to 77 in 2002.

Another challenge to providing the safest workingenvironment for employees, Dudley says, is getting those same employees tofollow these policies and use new devices can be difficult.

Training and acceptance are some big hurdlesfor us, she says. People dont like to change. When they getproficient with one device, they dont want to move to a different one. Eventhough we can see that the device may work better if they would just try it,take their time with it at first and get used to it, sometimes there isresistance.

With fervor, Dudley recognizes her work willnever be done. Im in the middle of all of it, she says.Im always asking, Are we always doing as good as we can? Our focusis prevention we want to prevent it from ever happening.