Twelve Years After Legislation, Sharps Safety Still a Concern in All Healthcare Settings

On Nov. 6, 2012, U.S. clinicians and sharps-device manufacturers celebrated the 12th anniversary of the Needlestick Safety and Prevention Act. Since the legislation was signed into law, the number of needlestick injuries decreased by one-third; however, the numbers of healthcare personnel at risk of injury can be staggering. Some numbers to consider:
- Approximately 150 million doses of flu vaccine will be administered across the U.S during the influenza season (one injection will be given to almost 1 in every 2 U.S. citizens).
- OSHA says 5.6 million workers in the U.S. healthcare industry are at risk of occupational exposure to bloodborne pathogens via needlestick injuries
- The CDC says that 385,000 needlestick injuries and other sharps-related injuries are sustained annually by hospital-based healthcare personnel.

Currently, the European Union (EU)s Health and Safety Executive is reviewing the need for needlestick regulations, with a May 2013 deadline. Mary Foley, PhD, chairperson for Safe in Common, a non-profit organization established to promote needlestick safety within the United States, has been speaking with the UK press on her recommendations for how the EU can learn from and build upon the mistakes of the U.S., including ignoring healthcare personal who work in clinics and physicians' offices who are still at high risk for sharps-related injuries. ICT sat down with Mary Foley to discuss these issues.

Q: As you travel around the country working with Safe in Common, what are you hearing from clinicians in terms of ongoing sharps safety-related issues? 
A: As I travel with Safe in Common (SIC), I am struck by two important findings. 1) Healthcare workers are anxious to talk about needlestick and sharp injuries, and are grateful that Safe in Common is working to raise this as an important issue in healthcare again, and 2) that workers are reporting injuries they continue to sustain. From student nurses to environmental workers to direct-care practitioners, not all equipment is safe, and even safety-engineered devices are leading to injuries.

Q: What are the lingering challenges in inpatient facilities? Outpatient facilities? 
A: I would have to acknowledge that acute-care facilities have in large part adopted safety engineered devices.  Many are the "first generation" devices that were released immediately after the passage of the 2000 Needlestick Safety and Prevention Act.  Many of those devices meet the intent of the law, but are not integral to the product, and require the healthcare worker to activate the protection. That are not passive or automatically safe. Many require two hands, or steps that my be difficult to perform in the heat of the delivery of care. However, in acute care, surgical settings continue to be areas of high risk, and that is the result of both the many "sharp" devices such as sutures scalpels, and towel clips. So, if the devices are not easily modified, the practices must be. That requires a change in behaviors, and that is not easily achieved. Outpatient/clinic/home care settings are relatively unstudied. Little is known either about the best devices, specific risk issues, or remedies to those concerns. Like surgery, non-acute care is in need of a concentrated focus to reduce risk and improve safety.
 
Q: Twelve years have passed since the needlestick legislation what has been accomplished and remains undone?
A: A lot has been accomplished but ongoing enforcement has been lacking, attention to non-acute settings has been absent, and newer and better devices are not making their way to practice settings. The focus on patient safety, while very important, has diverted the attention to worker safety. Instead, both safety agendas should be integrated, and priority given to work in both arenas. 

Q: Based on your experiences, and upon the Consensus Statement and Call to Action issued earlier this year, what should be the agenda moving forward?
A: The consensus statement helps focus the conversation on the "unfinished agenda" and should be a roadmap to what needs to be accomplished so the U.S. can really say it addressed the issue of sharp injury prevention in a comprehensive manner. I have always been impressed by Dr. Janine Jagger's work, and she not only introduced the notion of safer devices starting in the 1980s, but she continues to remind us of work that needs to be completed.

Q: What lessons from the U.S. should the UK consider, now that they are taking under advisement what our country has experienced? What has your experience been in the UK?
A: This is an opportunity for the UK to learn from the good work of 2000. Focus on non-hospital care, surgery, and special populations cannot be understated, and be sure that is built in to the current work. Also, be sure to require adequate enforcement efforts, or the non-acute settings will again slip through the cracks.

Q: What are your concerns about influenza season and safety-engineered devices?
A: My concern about the flu campaign is that many pharmaceutical companies make the drug, and then distribute it without any safety device built in. These products go to physician offices, grocery stores, and health departments across the country. Flu clinics include parking lots and airports, and without safety features, these devices put large numbers of skilled, and non-skilled staff at risk for injury. Not only is the care provider at risk, but so are the communities in which those devices will be disposed. That is wrong!  Protecting the public should not be traded off for risks to the care provider, or the community.

A Sharps Safety Call to Action

In the 12 years since the passage of the federal Needlestick Safety and Protection Act, much progress has been made to reduce the risk of healthcare worker exposure to bloodborne pathogensyet significant challenges remain. The International Healthcare Worker Safety Center at the University of Virginia and the American Nurses Association, along with colleagues across the spectrum of healthcare, have agreed on a Consensus Statement and Call to Action to address these issues.

We view this as a roadmap for future progress in preventing needlesticks, one of the most serious occupational risks healthcare workers face, according to Center director and UVa professor Janine Jagger, MPH, PhD.

The eight-page statement provides a snapshot of where we are now and where further work is needed in order to continue to protect healthcare workers from this risk they face every day in the line of duty, Jagger says.

The Call to Action focuses on five pivotal areas in need of attention:
1. Improve sharps safety in surgical settings
2. Understand and reduce exposure risks in non-hospital settings (which include physicians offices, clinics, home healthcare, and an array of other settings)
3. Involve frontline workers in the selection of safety devices
4. Address gaps in available safety devices, and encourage innovative designs and technology
5. Enhance worker education and training.

The idea for the Call to Action grew out of a 2010 conference organized by the Safety Center and supported by a grant from the National Institute for Occupational Safety and Health, marking the 10-year anniversary of the federal Needlestick Safety and Prevention Act. Attended by over 100 key opinion leaders in sharps injury prevention, including clinicians, researchers, and industry and government representatives, the conference explored the impact of the federal law in reducing sharps injuries and improving the safety of healthcare workers, both in the U.S. and globally. Conference participants agreed that while significant progress has been made over the previous decade and a half in reducing this risk in the U.S., more needs to be done. The Consensus Statement delineates the ongoing issues and current challenges in the field.

The Consensus Statement notes that healthcare workers in non-hospital settings account for about 65 percent of the U.S. healthcare workforcea proportion that will continue to grow over the next decade. While safety-engineered devices are in widespread use in most hospitals and clinical laboratories, market data show that their use in non-hospital settings lags behind. Health and Human Services agencies such as CDC/NIOSH and other government and non-governmental agencies and professional organizations need to support epidemiological research that evaluates risks to workers in a wide range of non-hospital settings, the statement says. It also urges professional organizations representing non-hospital care settings to make sharps safety a priority and ensure availability of appropriate devices and educational and training materials which are targeted for workers in these settings.

While we celebrate the progress we have made, we must acknowledge the gaps that exist," Jagger says. "We must redouble our efforts to ensure that all healthcare workers, regardless of the setting in which they practice or the procedures they perform, are offered the same standard of protection from sharps injuries and exposures to bloodborne pathogens.

The detailed recommendations from the consensus statement are:
1. Improve sharps safety in surgical settings
- Institutions adopt a site-specific sharps safety policy for the OR. Such a policy should mandate the availability, training, and use of specific sharps safety devices and implementation of risk mitigation strategies outlined by the ACS and AORN. When available and reasonable, users should be able to choose between several comparable and effective safety devices or personal protective equipment (scalpels, gloves, goggles, etc.) to suit their individual work practices, body sizes, and comfort. Sharps safety should not be an individual choice, since many injuries are sustained by workers other than the original users (and choosers) of devices.
- Surgeons, OR nurses and other surgical personnel work cooperatively to develop sharps safety standards and practices that are consistently implemented and followed in all surgical environments.
- Professional groups and manufacturers join forces to encourage the use of blunt suture needles for appropriate applications.
- OSHA place greater emphasis on Bloodborne Pathogen Standard compliance in surgical settings by evaluating overall adoption of safety devices to eliminate or minimize exposure risks. For example, compliance officers should determine if a facility encourages the use of blunt suture needles when clinically appropriate.

2. Understand and reduce exposure risks in non-hospital settings (which include physicians offices, clinics, home healthcare, and an array of other settings)
- Health and Human Services agencies such as CDC/NIOSH and other government and non-governmental agencies and professional organizations support epidemiological research that evaluates risks to workers in a wide range of non-hospital settings.
- OSHA promote regional emphasis programs that focus on enforcement of the Bloodborne Pathogen Standard in non-hospital settings; further, that other relevant groups, such as accrediting and licensing bodies and healthcare and workers compensation insurers enhance compliance incentives for non-hospital employers.
- Professional organizations and medical product distributors for non-hospital care settings collaborate to make sharps safety a priority and ensure that appropriate devices and educational and training materials are available which are targeted for workers in these settings.

3. Involve frontline workers in the selection of safety devices
- Organizations representing healthcare workers educate members about the legal obligation of employers to include frontline workers in the selection of safety devices. Members need to be encouraged to participate in this process.
- Hospital and healthcare employers consistently involve frontline healthcare workers in the selection and evaluation of safety devices, as is their obligation under the Bloodborne Pathogens Standard. Employers also need to enlist frontline workers in regular and systematic assessment of the devices currently in use in their institution, to ensure such devices are appropriate and, according to OSHA, eliminate or minimize employee exposure to the lowest feasible extent.
- NIOSH or another government agency consider funding research to assess whether and to what extent the requirement to include healthcare workers in the device selection process is being met in facilities across the country, and the ways in which this is being done. This research could provide the basis for developing a model program for frontline worker participation in device selection and evaluation.

4. Address gaps in available safety devices, and encourage innovative designs and technology
- Professional organizations partner with device manufacturers to assess and prioritize device needs for specific clinical applications, to monitor progress in closing existing gaps, and to identify future needs.
- Manufacturers partner with surgeons and surgeon groups to develop suture and scalpel safety designs that both reduce risk and are comfortable and intuitive for surgeons to use. Also, companies that provide pre-packaged surgical and procedure kits must ensure that devices included in these kits comply with the Bloodborne Pathogen Standard.

5. Enhance worker education and training
- CDC/NIOSH, OSHA, and/or other appropriate government agencies partner with medical, nursing, and allied health schools and accrediting bodies to develop standardized curricula on bloodborne pathogen exposure prevention and the selection and use of safety-engineered devices. Such training is an essential part of the education of all healthcare professionals (both at the beginning of and throughout their careers).
- Healthcare employers provide instruction on an annual basis for all potentially exposed clinicians and other workers (including service workers and purchasing agents) on the appropriate use and disposal of safety devices that are available in their facility, as mandated by OSHA. Such training provides a forum for addressing questions and issues that arise as new devices are introduced.
- Employers, professional educators, manufacturers and employee representatives collaborate to develop training strategies that can be widely applied when new devices are introduced, so that frontline healthcare workers know how to properly use and dispose of them. As a result of the leadership of our partners in the federal government and a variety of stakeholders, the U.S. has made tremendous progress in protecting healthcare workers from exposure to bloodborne pathogens. Other countries look to the Bloodborne Pathogen Standard and NSPA as models for their efforts to address this critical component of occupational safety in healthcare facilities. While we celebrate the progress we have made, we must acknowledge the gaps that exist and redouble our efforts to ensure that all healthcare workers, regardless of the setting in which they practice or the procedures they perform, are offered the same level of protection from sharps injuries and exposures to bloodborne pathogens.

The complete Consensus Statement, along with a complete list of endorsing organizations, can be viewed at the International Healthcare Worker Safety Center website at:  www.healthsystem.virginia.edu/internet/safetycenter