Sticky Situation
Despite needle safety legislation and technological advances, hospitals and health workers realize that reducing sharps injuries is no small task

By Phil Barber
August 5, 2003

When President Clinton signed the Needlestick Safety and Prevention Act into law Nov. 6, 2000, some saw it as a tremendous opportunity for health care workers. Others viewed it as a daunting challenge.

Laurie Gibson, RN, figured it was both. Under the law, each facility had to implement an exposure-control plan, review and (if necessary) purchase safer devices, create a log to document all future exposure incidents and meet CDC recommendations for post-exposure follow-up.

Gibson's small, nurse-run clinic Community Health Services in Scottsdale, Ariz., managed by the Arizona State University College of Nursing, already had an exposure-control plan in place thanks largely to her efforts. Because of her previous exposure to sharps (via immunizations, blood draws and fingersticks for hemoglobin and cholesterol testing), as well as her involvement in purchasing equipment, Gibson had emerged as an ideal candidate to formulate the plan.

But if the Scottsdale clinic was ahead of the game, it still wasn't necessarily in full compliance. So efforts were bumped up a notch. Gibson asked suppliers to send new equipment with built-in safety features. She and another nurse practiced first, then demonstrated the devices to the rest of the staff.

Some of the sharps drew pointed criticism. "One device had a sliding sheath, and it involved moving your thumb closer to the needle," Gibson said. "That didn't make sense to me. Another, when the needle retracted [into the syringe], it made a loud click. I didn't think that patients would respond well to that."

Fortunately, other pieces of new equipment made a better impression. In performing hematocrit testing on preschoolers (largely to gauge anemia), the Scottsdale clinic had used glass capillary tubes, which drew blood from the finger through capillary action. Gibson didn't like having breakable material next to the skin of young children, nor did she care for the tube-sealing method, which, to her mind, required too much manipulation. After the new guidelines went into effect, the clinic purchased a HemoCue machine that avoided these potential hazards.

Other new purchases were equally advantageous. "HemoCue also introduced us to a lancet that's a marvelous little tool," Gibson said. "You put the lancet device next to the spot where it will penetrate the skin, and you click the top. It pokes the finger, and the needle is immediately withdrawn into the housing. And it looks like a colorful Lego. It's nonthreatening."

Standards compliance

Gibson's Scottsdale clinic is not alone in its learning curve. After passage of the needlestick safety act, hospitals, clinics, doctors' offices and nursing homes across the nation hustled to comply with the new sharps-related standards by April 18, 2001.

No one working on a hospital floor questioned the need for such legislation. The CDC estimated an annual rate of more than 380,000 percutaneous injuries from contaminated sharps in American hospitals. For all health care settings, the yearly figure was anywhere from 600,000 to 1 million.

The American Nurses Association estimates that 1,000 or more health care workers contract serious infections each year from contaminated sharps. Hepatitis C and HIV, neither thwarted by any known vaccine, remain omnipresent concerns.

Has the workplace become safer for nurses since the passage of the Needlestick Safety and Prevention Act?

"Generally speaking, people are trying to be in compliance," said Butch de Castro, Ph.D., MSN, MPH, RN, senior staff specialist with the American Nurses Association's Center for Occupational Safety and Health. "It's definitely on the minds of the Occupational Safety and Health Administration compliance inspectors. Not to minimize [hospitals'] goodwill toward their staff, but the legislation certainly added some motivation."

Still, the industry seems to be substantially shy of 100-percent compliance. OSHA, admittedly hampered by its own staffing shortages, issued 673 citations for bloodborne pathogens violations between Oct. 1, 2001 and Sept. 30, 2002, including 93 for failing to incorporate adequate engineering controls. The bulk of the citations went to nursing homes, but hospitals received 111. On the bright side, total bloodborne pathogens violations were down from 768 in fiscal 2001; engineering-control violations were down slightly, from 98.

Already strapped for cash, many hospitals have found it difficult to budget for new, safer sharps, which can easily cost twice as much as traditional needles. Even those facilities willing to upgrade their technology experienced bumpy transitions, especially the larger players.

"The training is extremely challenging," said Barbara DeBaun, RN, director of infection control for California Pacific Medical Center in San Francisco, which employs about 1,300 nurses. "This is not an industry where everyone works full time. We have nurses who work here every other Tuesday. It wasn't so hard with new nurses, but grandfathering people who had been here for a while was definitely challenging."

According to DeBaun, her medical center had jump-started a needlestick prevention program at least a decade before the 2001 compliance date. But for most of that time, the technology lagged behind the intentions.

On board

"They passed this legislation, but they really didn't have the products to back it up," DeBaun said. "There were not a lot of choices. Some devices weren't good-either the quality was poor or they required so much manipulation that people were getting stuck more than they were with the old devices."

As DeBaun said, "Now, manufacturers are realizing this thing is here to stay. They're either going to jump on board or miss the train."

BD, a medical equipment manufacturer based in Franklin Lakes, N.J., is aiming to catch that train. In April, the company announced plans to fully discontinue U.S. sales of many conventional sharps in favor of safety-engineered designs.

BD estimates that U.S. hospitals have transitioned more than 80 percent of their IV catheters, "needleless" IV connectors, blood-drawing needles, winged needle sets and lancet sharps from conventional to safety-engineered designs.

Finding the best device can be a tricky proposition, too.

"The problem with this whole area of equipment," said Sean Clarke, Ph.D., NP, RN, who has led several needlestick studies for the Center for Health Outcomes and Policy Research (part of the University of Pennsylvania School of Nursing in Philadelphia), "is that the solid evidence [comparing pieces of] equipment is really very thin. It falls on the shoulders of hospital folks-infection control managers and nursing directors and so forth-to make calls on which manufacturers and models should be used."

Technology is only one weapon in the battle against sharps injuries. Federal regulators said as much when they drafted the bill to change the bloodborne pathogens standard. Of the six violations for which OSHA is empowered to hand out penalties, only one specifically mentions safety devices. The others have more to do with reporting and non-technological prevention.

Worker-friendly measures

Institutional support could be another weapon against sharps injuries. In their research on rates of needlestick injury and near miss, Clarke and his cohorts have reinforced the importance of institutional support, noting that the safest hospitals are the ones that maintain a worker-friendly environment.

Their 1998 study, for example, showed that using capless-valve secondary intravenous set systems and any type of protective equipment for IV starts or blood draws was associated with a 20 percent to 30 percent decrease in risk for needlesticks and near misses. Compare that with a 50 percent to twofold increase in injuries and near misses associated with poor organizational climate and high workloads.

In this study, respondents identified the most common risk-increasing factors as rushing in their jobs, uncooperative patients and carelessness of physicians and other nurses.

Clarke has been analyzing more recent data, gleaned from a huge sample of 42,000 nurses in 700 hospitals and six countries, and has found no reason to back away from his earlier analysis regarding institutional support.

"In Canada and the U.S.," he said, "the hospitals that make more of an investment-and I'm not necessarily talking about staffing, but good orientation, preceptorships, in-servicing and high standards of care-had lower rates [of injury or near miss].

"Basically, if a hospital has none of these things going on, compared to one that has everything going on, the rates are twice as high."

Traits among individual nurses seem to be just as important as those among hospitals.

In the 1998 study, needlestick injuries were significantly more likely among nurses with fewer than five years' experience, for those who punctured patients' veins frequently and for those who had routine blood draws and IV insertions added to their duties in the previous year.

This last fact is especially worrisome in light of the re-engineering of nursing work in the early 1990s, when many hospitals cut costs by disbanding dedicated IV-therapy teams. This forced staff nurses to assume new responsibilities, some of them inherently risky.

Much can be done to continue the trend toward greater safety. Further advances in technology certainly will help. So will the elimination of outmoded practices such as the recapping of needles.

The National Alliance for the Primary Prevention of Sharps Injuries suggests that the answer lies not simply in making needles safer, but in eliminating them whenever possible. An example is using Venetec's StatLock device, rather than sutures, for securing central venous catheters.

Others fret that OSHA's powers of enforcement are not vigorous enough to change the industry. State and municipal public hospital settings are not covered by the Needlestick Safety Act, nor are home health services. More important, the fines OSHA is able to levy are virtual slaps on the wrist.

The maximum fine is $7,000, and the average has been $655. Many fines are eventually adjusted downward after meetings with OSHA directors.

"The penalty system we're obligated to use was created when the original [bloodborne pathogen] act was established," said Amber Hogan, MPH, a senior industrial hygienist for OSHA. "That was 30 years ago."

Some nurses would prefer to go beyond the wallet when dealing with offending facilities. In Massachusetts, for example, hospitals' licenses are tied to compliance with safe sharps regulations.

Of course, not every safety control comes from the outside. Nurses must take responsibility for their own safety when using needles.

"No technology is going to save you if you don't follow the safety guidelines," DeBaun said. "You have to pay attention to the lighting in the room. Is the bed at the right angle? Get assistance if the patient is uncooperative. Nurses don't always take care of themselves."

Better education and more open discussion of needlestick injuries might well encourage nurses to protect themselves. Still, in this hazardous profession, one shouldn't expect the exposure rate to drop to zero.

"Until we are able to draw blood samples or put in a needle without using a sharp," Gibson said, "I think we're doing the best we can."

Contact Phil Barber at barzell@napanet.net