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Essential elements of a comprehensive sharps injury-prevention program
Since passage of the Needlestick Safety and Prevention Act (NSPA) in 2000, safer needle devices have become widely available in healthcare workplaces and needlestick injuries have declined significantly. Yet on many fronts, sharp injuries haven’t been addressed adequately. Healthcare delivery, devices, and demands have changed since 2000, and so has the science of safer devices. Even after the first decade of NSPA, large numbers of healthcare workers remain at serious risk for injury.
The goal of every healthcare facility should be to eliminate the risk of needlestick injuries wherever possible. The March 2012 report "Moving the Sharps Safety Agenda Forward in the United States: Consensus Statement and Call to Action" by the International Healthcare Worker Safety Center (IHWSC) aimed to energize comprehensive and expanded efforts to improve the safety of all healthcare workers. The document places special emphasis on workers in surgical or nonhospital settings.
IHWSC, the American Nurses Association, and 18 other healthcare and industry groups have focused on several areas of sharps injuries that still need attention. This article also discusses key issues that must be addressed by facilities hoping to achieve a universal and comprehensive reduction in sharps injuries.
Involve multiple disciplines in the prevention team
Healthcare facilities should establish multidisciplinary injury-prevention teams with representatives from all disciplines at risk for harm from bloodborne pathogen exposure. Frontline personnel (nonmanagerial employees responsible for direct patient care) should have the greatest level of representation. Other representatives should come from senior procurement administration, pharmacies, nursing unit management, staff safety, quality management, and infection control. "Downstream" at-risk workers, such as cleaning staff and those responsible for sharps disposal, should be represented as well.
Have an exposure control plan
Healthcare facilities should have a written exposure control plan, with a hard copy available to employees or their representatives within 15 working days of a request. The plan should be reviewed and updated annually or more often as needed, whenever new or modified procedures are adopted or employee positions are revised in a way that creates new potential exposures. The review should include an examination of the most recent technological advances in needle devices. Workers should be made aware of the plan location and the procedures to follow should a sharps injury occur.
Educate frontline workers
Many needlestick injuries occur because workers haven’t received adequate training on correct use of safety devices. While safety equipment should function as closely as possible to standard routine procedures, employee training is always recommended. Employees should receive education and training in the use of needle devices, injury prevention (such as how to dispose of needles properly), and infection control. All employees at risk for occupational exposure to bloodborne pathogens should receive interactive training on use of safer devices, safer work practices, and personal protective equipment (PPE) from a knowledgeable source. Such training should occur at the time of hiring and at least once yearly, or whenever the employee’s tasks or procedures are modified. Training must be provided during work hours at no cost, and employers must keep training records for 3 years.
Frontline workers need to be involved in evaluating and selecting needle devices; many nurses and employees don’t realize that this right to be involved is part of NSPA.
Take additional control measures
Additional control measures are especially important in surgical settings and other settings where traditional needle and syringe–based solutions won’t work, as well as nonhospital settings lacking the equipment and disposal infrastructure of hospitals. These control measures include the following:
•Postexposure evaluation and follow-up. Within 2 hours of a sharps injury or other potential exposure to bloodborne pathogens, employees should have access to postexposure evaluation and follow up that conforms to testing and prophylaxis guidelines of the Centers for Disease Control and Prevention (CDC). The hepatitis B vaccine should be made available at no cost, with titer verification as recommended.
•Sharps purchasing decisions. Purchasing decisions for sharps should be based on the products’ proven safety and efficacy.
•Prohibited work practices. Facilities should prohibit such practices as bending, recapping, and removing needles, unless required by a specific medical or dental procedure.
•Cleaning of work surfaces. After contact with blood and other infectious body fluids, work surfaces should be cleaned and decontaminated according to infection-control guidelines.
•PPE provision. Employers must provide PPE, including gloves, gowns, goggles, masks, and face shields, in sizes that fit all workers. PPE must be readily available and of good quality; nonlatex alternatives must be provided.
Use appropriate equipment selection criteria
The bloodborne pathogens standard of the Occupational Safety and Health Administration (OSHA) states that employers must use engineering and work-practice controls that eliminate occupational exposure or reduce it to the lowest feasible extent. OSHA classifies safety devices into the following categories:
•Passive safety devices remain in effect before, during and after use; workers do not have to activate them.
•Active devices require the worker to activate the safety mechanism.
•Integrated safety devices have a built-in safety feature that can’t be removed; this design feature usually is preferred.
•An accessory device is a safety feature that is external to the device and must be carried or be temporarily or permanently affixed to the point of use.
Some experts believe many needlestick injuries result from nonactivation of the safety device. Perception of poor compliance with activation influences many hospitals to select devices with a semiautomatic or passive activation feature.
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Enforce sharps injury reporting and records
Healthcare personnel should report needlestick injuries whenever they occur, and employers should maintain detailed records of all occupational exposures. OSHA and some states require a record of the brand and manufacturer of any device involved in a worker injury. To effectively monitor injuries, the following information should be recorded:
•unique identification number for the incident (to protect worker confidentiality)
•incident date and time
•injured worker’s occupation
•department or work area where the incident occurred
•type and brand of device involved
•presence or absence of an engineered sharps injury-prevention feature on the device involved
•purpose or procedure for which the device was being used
•when and how the injury occurred.
Other data that can enhance injury analysis include whether the device had a passive or active safety feature; whether the safety feature (if present) was fully integrated within the device and activated; whether the injury occurred before use, during use, while attempting to activate the safety mechanism, or after use; and whether the injury occurred while the worker followed standard recommended procedures.
Embrace a culture of safety
Needlestick injuries aren’t the sole transmission mode for bloodborne pathogens. Exposure also can occur to nonintact skin as well as mucous membranes of the eyes, nose, and throat. Other modes include aerosolization and splash or spatter of blood, tissue residue, or medication, which may occur with certain safety devices and reuse of nonsterile medical equipment. Although sharps injury prevention has gained renewed attention, healthcare facilities should embrace a culture of safety that seeks to minimize the risk of occupational exposure of all types in all areas.
The CDC recognizes the importance of a culture of safety, making it an integral part of its "Stop Sticks" campaign. The campaign emphasizes that maintaining a culture of safety helps protect patients, workers, and others in the healthcare environment. In such a culture, managers and nonmanagerial employees alike must commit to ensuring a safe work environment.
The CDC lists strategies for creating a safety culture:
•Ensure organizational commitment.
•Involve workers in planning and implementing activities that promote a safe healthcare environment.
•Identify and remove sharps injury hazards in the work environment.
•Develop feedback systems to increase safety awareness and promote individual accountability.
To achieve universal safety, all advocates must work together to unify agendas and maximize efforts to protect not just all healthcare workers but patients and families as well. Only then will we see the best results.
Practical strategies to prevent surgical sharps injuries
Perioperative professionals are among the healthcare professionals at highest risk for sharps injuries—getting stuck by a suture needle or cut by a scalpel. About 30% of sharps injuries occur in surgical settings. What’s more, since passage of the Needlestick Safety and Prevention Act in 2000, the rate of nonsurgical sharps injuries has declined while surgical sharps injuries have increased 6.5%.
Given these alarming statistics, we urge all nurses to review the American Nurses Association’s (ANA) Code of Ethics, provisions 5 and 6:
The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
The nurse participates in establishing, maintaining and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
These passages underscore our responsibility to keep ourselves safe and provide high-quality health care. To highlight exactly how we can do this, this article explores the current state of sharps safety practice and barriers to best practices, and outlines the key elements of an effective perioperative sharps safety plan and policy.
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Safety measures and barriers to sharps safety
Since 2000, numerous improvements have been made in safety scalpels and blunt-tip suture needle technology. Nurses, surgeons, and technologists have received many hours of education and training on double-gloving, the neutral (safe) passing zone, and appropriate use of blunt-tip suture needle technology. Yet surveys by the Association of PeriOperative Registered Nurses (AORN) and others show that many facilities still don’t follow best practices for sharps safety and vastly underreport needlestick injuries.
For instance, in 2011 AORN surveyed 1,111 perioperative staff nurses and unit directors on surgical sharps safety. Two of five respondents (43%) said either their organization didn’t have a sharps-prevention education plan or they didn’t know if it did. About one-third (30%) said they didn’t double-glove. When asked to identify obstacles to compliance with sharps safety best practices, 55% cited the fact that conventional sharp items are readily available; 52% cited lack of multidisciplinary support for sharps safety.
This isn’t surprising. While working in various facilities over the years, we’ve found significant barriers to implementing sharps safety plans and policies. These include organizational resistance to change; surgeons’ perceptions of the quality of safety needles; nurse intimidation and sense of powerlessness; the perception that safety costs more; and inaccurate beliefs, including "It’s not going to happen to me." Many people have suffered sharps injuries and haven’t contracted an illness, so they erroneously think they’re invincible.
To make best practices a reality, nurses should first get buy-in from the entire perioperative team (surgeons, technologists, and managers) by citing statistics, Occupational Safety and Health Administration (OSHA) regulations, and AORN-recommended practices. Next, they should use their champions to win administrative support for change. Finally, nurses should form a multidisciplinary team—along with physicians, the hospital safety officer, and representatives from risk management, work health, and infection control—to write and execute sharps injury-prevention plans and policies.
The case for blunt-tip suture needles
An analysis of injury surveillance data from 87 U.S. hospitals found 37.1% of surgical injuries occurred in surgical technicians, 30.3% in operating-room (OR) nurses, 17% in surgical residents and fellows, and 15.6% in surgeons. Injuries to nurses and technicians most often occurred when they passed or disassembled devices and during or after device disposal. Overall, suture needles were the most common cause of percutaneous injury in the OR, involved in up to 43% of such injuries.
Blunt-tip suture needles, available in almost all sizes and materials, are part of the solution. Although they require a bit more directed force than sharper needles, they can be used to suture less-dense tissue, such as muscle, fascia, and subcutaneous tissue. Their use was recommended in a joint safety communication issued in May 2012 by OSHA, the Food and Drug Administration, and the National Institute for Occupational Safety and Health: "Although blunt-tip suture needles currently cost some 70 cents more than their standard suture needle counterparts, the benefits of reducing the risk of serious and potentially fatal bloodborne infections for healthcare personnel support their use when clinically appropriate." The agencies strongly encourage healthcare professionals in surgical settings to use blunt-tip suture needles when appropriate.
Safe practices call for nurses to get involved in the solution. To get started, nurses should lead efforts to ensure that employers provide a selection of sutures in blunt-tip needle sizes comparable to previously used sharp suture needles. They should partner with materials management and worker health representatives, who can perform a cost analysis and analyze the financial implications of the more expensive blunt-tip suture needles versus the costs incurred from sharps injuries.
As a next step, nurses should update surgeons’ preference cards and list blunt needles on every card. They should work with suture company representatives to provide charts listing comparable needle sizes. Finally, nurses should identify a surgeon who uses blunt needles and is willing to champion the cause.
Scalpels are responsible for up to 17% of surgical sharps injuries—the second most frequent cause of these injuries. The solution is to use safety scalpels, which come in two forms: sheathed and retractable. Sheathed scalpels have a retractable plastic case that encloses the blade before and after use. Retractable scalpels let the surgeon or scrub person slide the blade into the handle with one gloved hand. Reported barriers to their use include complaints that safety scalpels lack the same weight and feel as metal-handled scalpels and aren’t as usable (the blades aren’t as sharp and can’t cut as deeply), and the perception that safety scalpels cause more injuries.
To promote safe practices, we recommend OR nurses advocate that their facility join sharps safety device trials to determine if one of the available safety scalpels would work for their facility. To get administrators’ buy-in, they should familiarize themselves with OSHA’s bloodborne pathogens standard, which requires annual evaluation and documentation of review of the use of engineering and work-practice controls to eliminate exposure to potential injury or reduce it to the lowest extent possible. Safety scalpels are an example of an engineering control that hospitals and ambulatory surgery centers could implement.
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Hands-free technique or neutral passing zone
Although getting perioperative team buy-in is optimal, nurses can initiate the hands-free technique (HFT) on their own simply by placing items in a container and passing the container to the surgeon. Research shows HFT reduces sharps injuries by up to 59%.
When using HFT, the scrub nurse places a suitably sized, puncture-resistant container, magnetic pad, or towel on the operating field between herself and the surgeon. The ideal device for HFT (also called a neutral passing zone) is large enough to hold sharps, not easily tipped over, and mobile. One sharp at a time is placed in the neutral zone before and after use. (Blunt instruments can still be passed hand-to-hand.) As the instrument is placed using the HFT, the user calls out "sharp" to alert the surgical team.Nurses should educate surgeons and OR staff members about HFT, noting it can be customized to each patient and surgery. For example, surgeons can identify situations when HFT won’t work, such as during ophthalmologic or microsurgical procedures. In those cases, nurses still may place instruments directly in the surgeon’s hand and then have the instrument returned to the neutral zone.
Glove punctures increase the risk of bloodborne pathogen trans-mission during surgery. Some research shows tears and perforations occur 6% to 12% of the time in the OR, especially when gloves are worn for long periods. During invasive surgical procedures, staff should change surgical gloves every 90 to 150 minutes. The Centers for Disease Control and Prevention, American College of Surgeons, Association of Surgical Technologists, and AORN recommend double-gloving during such procedures.
Wearing double gloves or using an indicator glove system helps protect healthcare workers from needlestick injuries. Designed to be used as the underglove, the indicator glove is a different color than a regular glove. Thus, tears and punctures are more easily visible, allowing surgical staff to more easily see breaches in the outer glove. Double-gloving itself acts as a protectant because punctures are more likely to breach the outer glove than the inner glove. Evidence shows that when healthcare workers wore a perforation-indicator glove, 77% of punctures were detected, compared to 21% detected when standard double gloves were worn.
Still, many facilities don’t require double-gloving, and even when they do, many perioperative personnel don’t double-glove. Resistance stems from the perception that double-gloving reduces their dexterity and tactile sensation. Another obstacle for some is the challenge of obtaining a comfortable fit.
As with other sharps safety techniques, to build compliance for double-gloving, nurses can start by using evidence to educate staff and adapting the technique to the individual facility. No single method of double-gloving works for everyone, so perioperative professionals should try different glove combinations and sizes to find a comfortable fit. Possible combinations include wearing two of the same-size gloves, wearing a half-size larger than the usual-size inner glove, and wearing a half-size larger as the outer glove. It’s a matter of personal preference and getting used to a different feel.
The ethics of sharps safety
The OR is unique in the healthcare facility: It requires close teamwork, with team members working under intense time pressure; reliance on limited visual cues; and extensive use of sharp, dangerous instruments. These circumstances put perioperative professionals at special risk for sharps injuries.
What’s more, healthcare workers aren’t the only potential victims of sharps injuries. Surgical patients have open wounds that are susceptible to contamination. If a scrub nurse or surgeon sustains a hand injury, their blood may contaminate patient wounds. Since 1991, 131 documented cases of healthcare worker-to-patient transmission of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus have occurred during invasive surgery worldwide.
Although every healthcare facility is unique, use of blunt-tip suture needles, safety-engineered devices, HFT for passing, and double-gloving have been found to reduce risk of sharps injuries across all settings. To uphold ANA’s Code of Ethics, nurses must use available devices for sharps injury prevention, educate others about their importance, and make sure our work environments are as safe as possible for every patient and every worker, every day.
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Reducing sharps injuries in nonhospital settings
Recently, one of this article’s coauthors had a nuclear medicine scan at an outpatient facility. She noticed the nurse used extreme caution when handling the syringe and needle loaded with the radioactive isotope, which had been carried in a lead box and handled with great care. But after the nurse administered the isotope, she used her bare hands to recap the conventional, hollow-bore needle that had just been in the patient’s vein.
How could this situation arise, in violation of the Needlestick Prevention Act—especially when handling such a highly contaminated device? This law applies to nonhospital settings as well as hospitals. In search of answers to questions like this, we conducted a survey of nonhospital workers to learn more about their unique issues. This article summarizes survey results and describes steps workers in nonhospital settings can take to reduce their risk of exposure to bloodborne pathogens.
Defining the problem
As more health care is delivered outside of hospitals to sicker patients undergoing more invasive procedures than ever, the need to reduce needlestick injuries in these settings is emerging as a key occupational safety issue. By a conservative estimate, about 40% of the nation’s 2.3 million registered nurses are employed in nonhospital settings.
In 2001, the Occupational Safety and Health Administration (OSHA) published and began enforcing a revised version of the bloodborne pathogens standard (BPS). Since then, use of safety-engineered devices has risen significantly.
The Centers for Disease Control and Prevention estimates that more than 380,000 parenteral blood exposures occur annually in U.S. healthcare workers. This means about 1 in 10 healthcare workers experiences a needlestick injury each year. Underreporting of needlesticks continues to hover around 40%.
The good news: The BPS has brought a significant reduction in hospital needlestick injuries. With hospitals generally moving in the right direction, needlestick prevention efforts have started to focus on nonhospital healthcare facilities, where such injuries are harder to track and injury rates are less well known. Nonhospital facilities encompass a wide variety of settings, including ambulatory and home care; outpatient, occupational health and public health clinics; surgery, dialysis, and rehabilitation centers; correctional facilities; nursing homes; and dental, medical, and nursing offices.
Some nonhospital employers may believe they’re exempt from the BPS because of their facility’s small size. However, all healthcare employers, including medical or dental offices and small clinics, are required to comply with the standard. Noncompliance puts healthcare workers at risk and can be costly to employers. Besides incurring OSHA fines (which can run into thousands of dollars), an occupational injury or infection can increase employers’ costs by:
•raising insurance rates, especially for self-insured employers
•increasing workers’ compensation payouts
•necessitating legal fees to defend against lawsuits by an injured worker or the worker’s union
•causing lost time at work by injured or exposed employees who need treatment and follow-up
•requiring the hiring of temporary or permanent replacement workers
•bringing negative publicity, which can damage the employer’s reputation.
On the other hand, complying with the BPS can bring multiple benefits, such as avoiding the increased costs described above and promoting a culture of safety that helps employers stay competitive in recruiting and retaining skilled employees. These factors should provide ample motivation for employers to get on board and improve their compliance with OSHA regulations.
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Survey of healthcare professionals in nonhospital settings
Reaching nonhospital nurses can be challenging, as many work in small clinical settings or as sole practitioners. So when the International Healthcare Worker Safety Center at the University of Virginia sponsored a webinar (“Achieving sharps safety compliance in nonhospital healthcare settings”) in August 2011, the authors took the opportunity to conduct a follow-up survey of participants to gather information on their attitudes toward and knowledge of needle safety and sharps injury prevention. After the webinar, we e-mailed the 571 registrants an invitation to take an online survey; of those contacted, 218 (38%) completed the survey. The resulting data, although not based on a statistically derived sample, provide interesting insights on sharps safety in nonhospital settings. Below are the survey questions and a summary of our findings:
•What is the best description of your worksite? Respondents worked in a wide variety of settings. The most common were physician offices, outpatient clinics, ambulatory care, and occupational health settings, followed closely by surgery centers and long-term care/rehabilitation centers. The largest occupational group in the survey identified themselves as nurses. Other occupations represented were administrators, infection-control practitioner, safety professionals , and educators/trainers
•Does your facility routinely use safety-engineered devices that protect healthcare workers from needlestick injuries? Almost 98% of respondents were aware of the BPS requirement to use safety-engineered devices. More than 96% of those with direct patient contact said they always or usually used safety-engineered devices, and about 90% indicated they always or usually were involved in selection of new devices. But nearly 10% said they were rarely or never involved in selection. OSHA requires that nonmanagerial employees responsible for direct patient care have input into device selection. This should be a focus for compliance improvement efforts in nonhospital settings.
•Do you feel confident in your ability to evaluate new safety-engineered devices that might be appropriate in your facility? Less than half of the respondents who were involved in evaluating new devices felt completely confident in their ability to evaluate them. More than half (59.7%) responded they would like resource tools to be made available and/or would like to receive more training on this process. Clearly, this is an area of need.
•What do you think are some of the barriers to using safety-engineered devices in nonhospital healthcare facilities? Encouragingly, about 30% of respondents indicated they saw no barriers to using such devices in their workplaces, and said they used only safety devices. But nearly 20% said their managers (owners, physicians, or dentists) don’t consider use of these devices to be a priority. Almost one-third agreed that the higher cost of the devices is prohibitive compared to that of conventional nonsafety devices. Another 17% indicated that the safety-engineered devices currently available don’t meet their clinical needs. Only six respondents perceived the risk of exposure to bloodborne pathogens in nonhospital settings as low.
Survey respondents, who represented a wide range of nonhospital healthcare settings, were fairly well-educated about needlestick prevention and BPS requirements. Many already were involved in sharps safety efforts in their facilities. Still, their responses clearly indicate some areas where more work is needed.
Responding to a needlestick
When needlesticks occur in nonhospital settings, responding in a timely and appropriate manner is important—although it can be challenging at times. The perception that workers in nonacute-care healthcare settings are at lower risk for bloodborne pathogen transmission than hospital workers is incorrect. Experts agree that the location or clinical setting of a needlestick isn’t relevant in assessing transmission risk. What matters is the type of device used (for example, a hollow-bore needle) and nature of the injury (for example, contamination of the device with blood). OSHA requires employees to receive immediate evaluation and follow-up treatment, as appropriate, by a qualified provider after blood exposure, regardless of the healthcare setting.
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Nurses and professional organizations need to renew efforts to reduce needlestick injuries in nonhospital settings. Consider taking the following actions:
•Increase your involvement in selection of safety-engineered devices. The BPS—and common sense—dictate participation of nonmanagerial, direct-care nurses. Personnel who use these devices should have a voice in their selection. So take an active interest and get involved in the selection process.
•Use device evaluation resources to help find and evaluate safety-engineered devices. Many online resources are available, but workers in nonhospital settings may be unaware of these. Professional organizations for providers in these settings can play a role in getting this critical information to members.
•Hold employers, managers, and small-practice owners accountable for meeting BPS requirements. OSHA is clear that employers have a responsibility to evaluate and implement safety-engineered devices. The agency doesn’t exempt employers from providing safety-engineered devices on the grounds of cost.
•Look for opportunities to collaborate with manufacturers and researchers to ensure new devices meet the unique needs of nonhospital settings. Many nonhospital settings present unique challenges in healthcare delivery. They may be poorly lit, involve unruly or violent patients, require clinicians to practice in isolated settings with scarce resources, or involve complex procedures previously done only in hospitals. Nurses can provide critical input into device design and selection so their clinical needs are taken into account.
•Know your facility’s plan for needlestick injury response. Many nonhospital health services are delivered in community-based settings where access to prompt treatment can be challenging. Optimally, evaluation and treatment should occur within 2 hours of a needlestick. Be sure you know how to get prompt and proper care.
By working together with professional organizations, manufacturers, researchers, educators, and regulators, we can improve the safety and health of all workers in nonhospital settings.