Many physicians’ offices lag behind hospitals, but therein lies the sales opportunity
Sales reps know that change is in store – some of it good, some maybe not so good –when the local hospital system acquires one of their physician practice customers. Increased sales of safety-engineered sharps – that is, safety needles and syringes, phlebotomy devices, sutures, etc. – may very well be one of those changes.
The law clearly states that physicians offices – even solo practitioners – should have evaluated and switched to safety sharps a long time ago. But sometimes it takes the watchful – and cautious – eye of hospital administrators and infection prevention professionals to jolt freestanding offices into action.
U.S. healthcare workers sustain an estimated 600,000 percutaneous injuries involving contaminated sharps per year, says Gina Pugliese, RN, MS, FSHEA, vice president of Premier Safety Institute, citing statistics from the Centers for Disease Control and Prevention. Of them, 400,000 are among hospital workers, meaning 200,000 occur outside the hospital, including physician offices, clinics, home care settings, etc. “And this number is probably low, since under-reporting is a continuing problem,” she says.
Blood Pathogens Standard
Physician offices are required to use safety devices whenever possible. OSHA’s Bloodborne Pathogens Standard, including its 2001 revisions, applies to all employers who have employees with occupational exposure, i.e., reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials. Even solo practitioners are required to have in place an Exposure Control Plan, that is, a written program outlining the protective measures the employer will take to eliminate or minimize employee exposure to blood and other potentially infectious material.
What’s more, the law states that employees must be involved in decisions about which safety products to use. Front-line, clinical workers are specifically named in the OSHA regulations, points out Pugliese. These regulations read, “An employer…shall solicit input from non-managerial employees responsible for direct patient care …in the identification, evaluation, and selection of effective engineering and work practice controls.” [1910.1030, paragraph (C)(1((ii)]
But in fact, the Occupational Safety and Health Administration has focused its attention on larger healthcare facilities, says Pugliese. “This enforcement strategy has encouraged hospitals to switch to safety-engineered devices.” Now OSHA is beginning to look more closely at office practices and outpatient clinics. And with good reason.
“The key question is not, ‘Who is using what?’ but rather, ‘Is the risk different enough to warrant not using safety-engineered devices in physician offices?’” she says. The risk is the same with any given procedure, regardless of where it is performed. “For example, the risk from a needlestick incurred during phlebotomy is the same, regardless of whether it is performed in a hospital or in an office.”
Impact of hospital acquisition
Though it is difficult to quantify the impact that hospital acquisition of physician practices has had – or will have – on the implementation of safety-engineered devices, “certainly large healthcare organizations would be looking at affiliated practices to assess whether they meet the requirements of OSHA, The Joint Commission and local health departments,” says Pugliese.
“The issue is, nobody has ever regulated the physician’s office,” says Kim Strelczyk, RN, MSN, ACNS-BC, CIC, consultant, Specialists in Infection Prevention & Control LLC. “But good practices know that the OSHA Bloodborne Pathogens Standard applies to any employer who has employees who use sharps and may be exposed to blood and other potentially infectious fluid,” says Strelczyk, who gave a presentation at this summer’s APIC 2014 Annual Conference in Anaheim, Calif., titled “The Changing Infection Prevention Program – It’s Not Just for Hospitals: Expanding your Program to Include Hospital-Owned Clinics.”
“The really good ones assign someone in their office to make sure they comply with the Standard, and they have an annual education event,” she says. “But in other practices, it’s a situation where nobody ever told them [about the Standard], or it went right over their head. It’s not until the hospital buys the practice that they find out.” At that point, it becomes the responsibility of the hospitals’ infection prevention team to bring the practices up to speed.
Strelczyk recalls consulting one hospital system some time after it had acquired 36 clinics. It was clear that it had been years – if ever – since an infection prevention professional had set foot inside the offices, she says. At that time, there wasn’t a blueprint to show hospital systems how to bring newly acquired practices into compliance with the Bloodborne Pathogens Standard. Strelczyk found such a blueprint in the CDC document “Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care” (http://www.cdc.gov/hai/pdfs/guidelines/ambulatory-care-04-2011.pdf).
Converting the practice
Step 1 is getting into the clinic(s) and “doing a quick and dirty assessment” to determine how bad – or good – the practice is from an infection control perspective, says Strelczyk. “From there, you figure out what resources you’ll need to make changes.”
There are procedures for which the caregiver team cannot use a safety-engineered device. “But by and large, 99 percent of what we do can be done with safety devices,” she says. “There are dozens and dozens of brands, and they all work a little differently; they have a little bit different mechanism to deploy the safety device. So we have to trial them and see what works best for the staff.”
However, for some physicians, old habits die hard. “As hard as we try, we still find people who have a stash of their favorite needles and syringes in a locker,” she says. Some IDNs have addressed the situation by insisting that a department or outpatient center purchase non-safety-engineered devices only with approval from the infection prevention department.
“But we continue to have outbreaks of hepatitis B and C as a result of [poor infection control and safety practices],” she says. “It’s unbelievable.”
In the case of the hospital system that had acquired 36 clinics, Strelczyk and her team assembled the office managers from each of the clinics and went through the basics of infection prevention. “We had pictures I had taken in some of the clinics, and offered tips of what to do and what not to do,” she says. The office managers then shared that information with their staffs.
“It’s not rocket science,” she says, referring to the topics covered with the managers. “We were talking about basic safety, cleanliness and simple things, such as, ‘What do you do when you have a coughing patient in the waiting room?’” (Answer: Give them a mask and get them into an exam room, away from other patients.) Many practices fail to monitor their sterilizers properly, she adds. “Practices almost always have a tabletop sterilizer, and they almost never do the monitoring correctly.”
It’s not uncommon for the hospital system’s infection prevention team to meet some resistance from the staff of newly acquired physician practices, continues Strelczyk. “Often, the people [in the practices] have been there a long time, they’ve done things a certain way, and now, some new person comes in and asks, ‘Why are you doing that?’”
Selling safety devices
Some practices believe their patients are “low risk” for diseases such as HIV, HBV and HCV, says Pugliese. “This is simply not true. Since no one can tell by appearance who is infected, all blood must be treated as potentially infectious. Recent reports of dramatic increases in HCV among the ‘Boomer’ generation, the increased treatment of HIV in community settings, and the proliferation of body tattoos make universal precautions more important than ever in the office practice.”
Some practices may object to the marginally higher cost of safety-engineered devices. That said, “OSHA does not accept cost as a solitary criteria for device selection,” says Pugliese. The law states, “Selecting a safer device based solely on the lowest cost is not appropriate. Selection must be based on employee feedback and device effectiveness.”
Sharps containers
Safety devices include sharps containers. Data from 2000-2006 shows that 36 percent of injuries occurred during the use of the sharp, and 16 percent occurred after use prior to disposal, says Pugliese, citing data from the US EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Research Group of the International Healthcare Worker Safety Center of the University of Virginia. That means that as many as 48 percent of injuries occurred during or after disposal.
“It is essential that disposal boxes be located at the point of use,” says Pugliese. “[The National Institute for Occupational Safety and Health (NIOSH) of the CDC] has developed specific descriptions for disposal boxes that can be used in the selection and placement of these tools.”
Sales reps who meet resistance to safety-engineered devices based on purchase price should point out that in a recent study, the baseline cost of a needlestick was estimated between $400 and $6,000, not including follow-up testing, visits by the infectious disease physician, medications, etc. “This cost, in addition to time lost and emotional trauma, should be considered in the overall economic analysis of the cost for safer devices,” says Pugliese.
“Using – not just buying and storing – safety-engineered devices and having an established plan to involve front-line employees in the selection process will surely be an asset for any practice. These steps may also affect worker compensation rates for the practice and will, in the long run, make economic sense.”
Key steps in the product evaluation process
The Centers for Disease Control and Prevention suggests that healthcare providers adopt an 11-step approach to the evaluation of safety-engineered devices:
Step 1: Organize a product selection and evaluation team.
Step 2: Set priorities for product consideration.
Step 3: Gather information on use of the conventional device.
Step 4: Determine selection criteria.
Step 5: Obtain information on available products.
Step 6: Obtain samples of devices under consideration.
Step 7: Develop a product evaluation form.
Step 8: Develop and implement a product evaluation plan.
Step 9: Tabulate and analyze the evaluation results.
Step 10: Select and implement the preferred product.
Step 11: Perform post-implementation monitoring
Source: “Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program,” Centers for Disease Control and Prevention, page 51. (May be downloaded from Premier Inc.’s, website at https://www.premierinc.com/quality-safety/tools-services/safety/topics/needlestick/downloads/sharps-workbook-2008-high.pdf).
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