Things are getting better. But ‘better’ isn’t ‘great.’
Twenty-six years after the OSHA Bloodborne Pathogens Standard and 18 years after the Needlestick Safety and Prevention Act, people are still getting stuck with sharps – doctors, nurses, phlebotomists, environmental services staff, and others. Part of that is due to shortcomings in safety technology. But human factors – including inadequate staffing and a pressure to see more patients can result in a lack of concentration, a lack of knowledge or a failure to best prepare for adverse events – are also factors.
Repertoire spoke with Amber Hogan Mitchell, DrPH, MPH, CPH, president and executive director of the International Safety Center. The Center is a non-profit organization that provides the Exposure Prevention Information Network (EPINet®) to healthcare facilities around the world. EPINet provides healthcare facilities with a standardized system for tracking occupational exposures that put healthcare staff at risk. The EPINet surveillance system includes employee incident reports on needlestick and sharp object injuries and on blood and body fluid exposures.
Repertoire: Are you optimistic about what is occurring insofar as sharps safety is concerned, or are you concerned?
Amber Mitchell
Amber Mitchell: There have been successes that help us maintain optimism, but there have also been ongoing challenges that continue to frustrate professionals in the field of sharps injury prevention. Successes have included improvements in innovative safer device design, which have resulted in reduced injuries in blood collection, IV insertion and infusion.
However, injuries from sutures continue to climb, especially among physicians. According to our 2017 Exposure Prevention Information Network (EPINet®) Summary Data, injuries from suture injuries (26.1 percent) have now surpassed injuries from disposable hypodermic needles/syringes (24.6 percent). More needs to be done to move uptake of alternate technologies for skin closure, where blunt tip sutures cannot be used.
Also, as it relates to injuries from hypodermic syringes, 27.2 percent are from insulin needles. Healthcare facilities – including long-term care, behavioral health, schools, and wherever else needles are being used to inject insulin – should evaluate and consider the use of safer devices, including sharps injury prevention (SIP) needles for syringes used with vials and pen needles.
We still see a discouragingly high percentage of injuries occurring from recapping and inappropriate disposal. These types of injuries are 100 percent preventable with better practice and improvements in accessibility to sharps containers.
Finally, when employees indicate they were injured from a needle or sharp, more than 30 percent say they were from devices with safety features; of those, more than 65 percent did not activate the safety feature. If they did, almost 20 percent indicate that the injury occurred after safety mechanism activation.
Repertoire: How can injuries occur after activation of the safety mechanism?
Mitchell: If frontline patient-care providers were not involved in the identification, evaluation and selection of devices with safety mechanisms, the user may not know how to best operate its features. The clinician may push too hard – or not hard enough – on a sheath, button or needle cover. Or he or she may not be aware that the safety mechanism is supposed to have an audible click to lock. This can result in an injury and is the reason why compliance with the OSHA Bloodborne Pathogens Standard is so important with regard to frontline, non-managerial employee involvement in device selection.
Our focus moving forward really has to be not just on the uptake of devices with safety mechanisms, but also making sure that employees evaluate and select devices that improve compliance with safety mechanism activation, and that the safety mechanism offers full protection after it has been activated. This ensures not just the safety of the user, but also anyone who may encounter it downstream, such as those in environmental services, laundry, waste haulers, team members, etc.
What’s more, according to EPINet data, 49 percent of injuries from devices with safety mechanisms occur before those features can be activated, because the patient may have jumped or jarred. Future device designs should incorporate patient comfort elements that decrease pain and discomfort for the patient. These features can improve not just patient safety, but also worker safety and well-being. An important area of focus should be blood collection and skin injection, as these two procedure types make up the majority of incidents occurring in the patient or exam room when the patient is conscious.
All safety features – including active, passive and those I call “passively active,” like IV stylets, can be subject to failure, just like with any medical device or instrument. The best way to prevent sharps injuries is adhering to the hierarchy of controls and identifying ways to eliminate the use of sharps if possible. An example for reducing suture injuries from skin closure might be the use of new technologies, including adhesives and zipper-like closures.
In the OR
Repertoire: In November 2017, you and two co-authors published an article in Infection Control Today titled “Sharps Injuries Remain Major Occupational Safety Concern for Healthcare Personnel.” In it you point out that evidence suggests that OR sharps injuries are actually increasing. What do you make of that?
Mitchell: Nurses are making great strides in improving uptake of devices with safer designs, especially in patient and exam rooms and procedure rooms. Unfortunately, injuries in the OR (sutures and scalpel blades) are on the rise, especially among physicians and to non-users. This means that uptake of SIP devices among physician communities is lower than nursing communities, and that in the OR, injuries are occurring to surgical team members from unsafe hand-to-hand passing or when devices are not disposed of safely.
Focus in the OR should be on instituting safer practices for no-hands, neutral zone passing; better uptake of alternates for skin closure; improvements in use of blunt tip sutures for internal fascia and muscle; and an uptake of safer devices for cutting (disposable and reusable scalpels with safety features) as well as innovative designs for cutting devices that reduce injuries.
With the ongoing pressure to increase patient turnover and increase numbers of surgeries from a financial point of view, we need to tackle this issue now before injuries increase exponentially.
Repertoire: The article also says that as many as 80 percent of sharps injuries from 2010 to 2015 involved devices that lacked an engineered sharps injury protection mechanism. I thought engineered sharps injury protection mechanisms were mandated by law. What am I missing?
Mitchell: Unfortunately, despite the requirement to use engineering controls, including those with sharps injury protection features, since 1992 with the OSHA Bloodborne Pathogens Standard, and then renewed focus from the 2000 incorporations from the Needlestick Safety and Prevention Act, uptake is much lower than ideal. Sharps that lack safety features are still available on the market. If they cost less than safety devices, even despite federal regulations, people will still buy them. In other cases, the end user may put together syringes with non-safety needles, or non-safety scalpel handles with non-safety blades. Manufacturers need to work on innovative ways to get around this and to make sure that users are protected.
We cannot lose focus on improving uptake of current SIP devices; improving designs to increase safety feature activation; designing devices that eliminate the need for a sharp/needle; and continuing to provide ongoing training and education not just about device use but about risk and risk mitigation. This includes making sure the data that a facility collects are being put to use.
Robust surveillance systems like EPINet are a way to identify exactly where injuries are occurring and from what types of procedures and devices. It also allows a facility to focus efforts on targeted intervention programs that can have measurable impact. It is also critical to provide feedback to manufacturers and distributors so that they know what’s happening and how to improve in-servicing and device design.
Repertoire: Downstream injuries appear to be a nagging problem. How are successful healthcare providers helping environmental services and members of the clinical team avoid such injuries?
Mitchell: Nearly 30 percent of all sharps injuries and needlesticks happen to non-users. These include not just members of clinical teams, but environmental services, laundry, waste haulers, visitors, and administrative staff. These are groups that did not knowingly sign up for that kind of risk at work. Incorporating a comprehensive sharps safety program into any facility or community means that we are protecting not just clinical users of devices, but anyone who may come into contact with devices later in the disposal or waste stream.
Even if we become complacent about protecting ourselves, we should never lose sight of our role in protecting those around us. Sharps safety is really a poignant public health issue for this very reason, especially as emerging infectious diseases continue to remain a global threat.
Properly disposing of sharps in sharps containers is important in preventing downstream injuries. Just as important is taking precautions against injuring others on the clinical team. In the OR, that means no more hand-to-hand passing of sharps; use of a neutral zone is preferred. Some providers have gone so far as to institute mini timeouts prior to use of a sharp at the bedside, particularly important in crowded patient rooms. In such cases, the caregiver might announce, “I am about to give an injection. Be still. Be aware. Be careful.” If you fail to do this, you risk turning around and accidently injuring the person behind or next to you.
Get the total staff involved
Repertoire: You have reported that inactivation of sharps injury prevention mechanisms was associated with about 72 percent of reported downstream injuries in the OR. Even today, people are still failing to activate safety mechanisms? How can that be?
Mitchell: They may not be familiar or comfortable with the safety mechanisms in use at their facilities.
One of the most overlooked requirements of the OSHA Bloodborne Pathogens is the following requirement: “An employer, who is required to establish an Exposure Control Plan, shall solicit input from non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in the Exposure Control Plan.” 1910.103(c)(1)(v).
This means that device evaluation must not just be done by device committees, materials management or purchasing. Rather frontline employees must be active in identifying, evaluating, and selecting devices. This serves several purposes. First, compliance with the intent of the standard is achieved. Second, well-rounded and comprehensive feedback is collected. Third, the safest devices are selected that positively impact both patient and worker safety. Finally, improvements with safety feature activation take place because employees are using devices that are intuitive and are ones they feel most comfortable with. Win, win, win, win.
Repertoire: Can you comment on sharps injuries in non-acute settings, particularly the physician office or skilled nursing facility?
Mitchell: Sharps injuries that occur outside of acute-care hospital settings can be even more devastating than those occurring in hospital settings. This may seem counter-intuitive, but consider that hospitals have tons of resources, employees, departments, committees, funds, and expertise. Offices, clinics, outpatient settings, long term care, behavioral health, home health and other faster growing segments of healthcare are limited in staffing, size and access to expertise. What’s more, they often have greater geographical reach with higher patient loads.
A sharps injury in an office setting can mean that one of a staff of four or five is now unable to perform patient care. That can be devastating not only to the person being injured, but to the office and its ability to keep up its patient load, not to mention its reputation in the community and with employee recruitment. Incorporating the safer devices in smaller health settings makes more business sense than in any larger facility. That isn’t to say that it doesn’t make business sense in hospitals. It unequivocally does. But the impact can be seen more clearly and more immediately in an outpatient setting.
Non-hospital settings typically do not have full-time employee or occupational health professionals nor infection preventionists, which is all the more reason to rely on networking, building awareness, relying on external stakeholders, and partnering with organizations like the International Safety Center. They can help them build their programs at no or minimal cost – with big impact.
Facts about sharps injuries
- Injuries from suture injuries (26.1 percent) have now surpassed injuries from disposable hypodermic needles/syringes (24.6 percent).
- Of injuries from hypodermic syringes, 27.2 percent are from insulin needles.
- When employees indicate they were injured from a needle or sharp, more than 30 percent say they were from devices with safety features. Of those, more than 65 percent did not activate the safety feature. And if they did, almost 20 percent indicate that the injury occurred after safety mechanism activation.
- Forty-nine percent of injuries from devices with safety mechanisms occur before those features can be activated, because the patient may have jumped or jarred.
- Nearly 30 percent of all sharps injuries and needlesticks happen to non-users (e.g., members of clinical teams, environmental services, laundry, waste haulers, visitors, and administrative staff).