Ten years safer. But safe enough?

The Needlestick Safety and Prevention Act was signed into law nearly 10 years ago. Where does the healthcare industry stand today?

It wasn’t enough to simply tell healthcare practitioners and nurses to be careful around needles and syringes. When the Needlestick Safety and Prevention Act was signed into law on Nov. 6, 2000, its intent was for employers to identify, evaluate and implement safer medical devices. Today, many experts agree that healthcare settings have become safer environments for clinicians, nurses, other workers and patients. At the same time, they question whether more needs to be done.

Healthcare workers and their patients deserve the safest conditions possible, according to Elizabeth Ann Vencill, MHA, MBA, CLS, MT (ASCP), SLS (ASCP), PBT (ASCP), Memorial Medical Center, Modesto, Calif. Thanks to the Needlestick Safety and Prevention Act, clinicians such as Vencill have moved much closer to realizing this goal. “The Needlestick Safety and Prevention Act enabled healthcare organizations to devote resources, both financial and personnel, to thinking about the effects that needlestick injuries had on the employee population,” she says. “We realized we could not ask healthcare personnel to continue to put themselves at such risk [for contamination from HIV/AIDS and other bloodborne pathogens], or we would denude ourselves of these services.”

That’s no exaggeration, Vencill continues. “Some of my friends [and coworkers] became ill and later died as the result of being laboratorians, nurses and doctors, because our practices in the 1980s and 1990s were not as stringent as they are today,” she explains. Many other friends and colleagues left the healthcare industry to avoid such risks, she adds.

The Needlestick Safety and Prevention Act enabled clinicians and healthcare employers to reflect “and to discover that simply saying to someone, ‘You must be more careful when performing a random healthcare action,’ was not enough to save their lives,” Vencill continues. As a result, the industry is “fabulously safer,” she says, and physicians, nurses and healthcare workers have safer tools at their disposal, such as single-use test tubes holders and clave connectors for needleless access to IV tubing.

At Memorial Medical Center, seven years ago the needlestick injury rate to the phlebotomy staff alone was about six incidents annually, according to Vencill. Today, while the medical center’s number of beds has increased from 350 to 423, and the phlebotomy staff has increased from between two and four full time employees to between three and six full time employees, needlestick injuries rarely, if ever, occur.

“This means that our staff’s families will not face the terror of uncertainty from a needlestick injury,” says Vencill. “It means the hospital will not incur the expense of needlestick injury mitigation. There is less turnover of employees from [the fear of injury] and fewer immediate care costs, [including] blood tests, call backs and doctor visits and employee health visits.”

What are the safety challenges today?
As safe as the healthcare industry is today, it can always be safer, according to experts. “Great strides have been made in minimizing needlestick injury risk through the use of safety-engineered products for blood-drawing procedures, which present a high risk of bloodborne pathogen transmission,” says Angela Karpf, MD, worldwide medical director, BD Medical-Medical Surgical Systems. “While progress has been made to reduce occupational exposure to bloodborne pathogens, sharps injury continues at occur at an unacceptable rate.”

“In blood collection, the risk of needlestick injury from the back end of the phlebotomy needles (the end puncturing the blood collection tube) may not be readily apparent, because the needle is covered with a rubber sleeve,” adds Ana Stankovic, MD, PhD, MSPH, worldwide vice president, medical and scientific affairs and clinical operations, BD Diagnostics-Preanalytical Systems. “These injuries may be directly related to removing the needle from the blood collection tube holder. Another issue is associated with activation of the safety feature. To achieve maximum benefits of safety-engineered devices, it is essential that the devices’ safety features be engaged appropriately.”

“In addition to the risks of needlestick injury to healthcare workers, there are also significant risks for non-users of sharps devices, such as clinical staff, housekeepers, maintenance personnel, waste management personnel and administrative personnel,” Karpf points out. “Injuries typically occur because of poor disposal practices, sharps left in linens or thrown in regular waste streams, hand-to-hand passing of instruments, and during cleaning/sterilization. Injuries that occur to downstream/non-user employees are of particular concern since the sharp device causing the injury can be of unknown origin and contamination history, making medical follow-up and post-exposure prophylaxis challenging to prescribe.

“New and rejuvenated efforts need to be put forward to educate new professionals and re-educate experienced professionals about sharps safety, standard compliance and the interaction between healthcare workers and patient safety with regard to exposure to blood and body fluids,” she continues. “In addition, annual review of available technologies, as well as appropriate training on the use of safety-engineered devices, is required to effectively reduce the incidence of accidental sharps injuries. Compliance with training and an audit of training records on a regular basis will further enforce the correct and proper use of safety-engineered devices.”

User’s choice
Gina Pugliese, vice president, Premier Safety Institute (Charlotte, N.C.) is confident that healthcare settings are safer today than they were before the Needlestick Safety and Prevention Act was signed into law. However, several factors continue to influence healthcare safety. For instance, although the Occupational Safety and Health Administration (OSHA) requires physicians, nurses and other healthcare workers to use safe safety devices, the users get to select the safety device they are most comfortable using, she points out.

In a study by the Safety Institute of 25 hospitals, over 800 clinicians cited patient safety and the ability of a syringe to deliver an accurate dose of a medication, rather than worker safety, as the most important safety feature. “Among the top five preferred features for syringes were the reliability of the safety feature, the ability of hands to remain behind the needle and the ability of the syringe to function for its intended use,” says Pugliese. Other issues that may influence user preference include the intuitiveness and ease of use of a safety device, the degree of change in technique needed to use it, and visible or audible indication of activation, she adds.

In addition to user preference, the way a clinician or healthcare worker uses the device impacts its safety, Pugliese continues. “What techniques do they use?” she says. “When is the injury occurring? If they use a manually activated safety device and delay activation or don’t activate it before disposal, it doesn’t do a lot of good.” Also, the level of patient comfort associated with a particular device may impact when it is activated, she notes. “For example, when using a semi-automatic retractable needle-syringe, clinicians may perceive an issue with patient comfort if they retract the needle while it’s still in the patient’s arm,” she says.

Finally, in some cases, user preference can be a matter of habit. Despite a 2007 study by the Centers for Disease Control and Prevention showing that blunt suture needle use could substantially reduce needlesticks, the current adoption rate is less than ideal, according to many experts. A study by Janine Jagger, MPH, PhD, Ramon Berguer, MD, FACS, Elayne Kornblatt Phillips, RN, MPH, PhD, Ginger Parker, MBA and Ahmed Gomaa, MD, ScD, points to an increase in percutaneous injuries in the operating room. “In part, this is because safety devices like blunt suture needles and safety scalpels are not being readily adopted,” says Pugliese. “The surgeon’s choice to avoid using the safest device available can affect his or her whole team. “When the surgeon passes [an unsafe device] to the nurse, he or she puts him or her at risk.”

Educating customers
The smallest needlestick can lead to the greatest of health issues, and as smart as the healthcare industry has become, it can be smarter yet, note experts. “Even the smallest skin puncture caused by a needle or other sharp device can expose healthcare workers or healthcare facility employees to more than 30 bloodborne pathogens, which can cause serious and potentially life-threatening infections,” says Karpf.

“While the direct costs of a needlestick injury can be readily calculated, the human costs cannot,” says Stankovic. “Even when there is no transmission of a serious or life-threatening disease, the emotional distress of a needlestick injury can be severe and long-term. This is especially true if the injury involves exposure to human immunodeficiency virus. The uncertainty of the infection status of the source patient can also create anxiety that may extend to coworkers, friends and family members.”

The economic cost to the victim depends on the type of infection, Vencill points out. “If we are talking about, say, a bacterial infection, then antibiotics would be used, and hopefully full recovery made. If we are talking about HIV/AIDS, the cost is a lifetime of rigorous antiretroviral treatments worth millions of dollars, just for the employee.

“But, the cost to the family is nearly incalculable,” she continues. Relationships change (emotionally and physically), as do people’s ambitions and dreams, she notes, pointing to colleagues and friends she has known who have fallen victim to needlestick injury and missed their children’s proms, graduations and other milestones. “Chronic illness becomes the elephant in the living room,” she says.

What then, needs to be done? “While great strides have been made since the development of the Standard nearly 20 years ago, additional progress could be made to improve compliance in non-hospital settings and operating rooms, to educate and train professionals about sharps safety and engage frontline healthcare workers in the evaluation of and selection of safety-engineered devices,” says Karpf.

“The annual review of available technologies, as well as appropriate training on the use of safety-engineered devices, is required to effectively reduce the incidence of accidental sharps injuries,” she continues. “Compliance with training and an audit of training records on a regular basis will further enforce the correct and proper use of safety-engineered devices.”

Indeed, continued education of clinicians and healthcare workers is key, Vencill notes. The use of needles, scalpels and blood collection devices comes with a lot of responsibility, she points out. To place a patient or healthcare worker at risk “over a dollar is penny wise and pound foolish.”

Editor’s note: For more information, please refer to a recent multi-hospital study by Dr. William Tosini and colleagues, “Needlestick Injury Rates According to Different types of Safety-Engineered Devices: Results of a French Multicenter Study,” 2010, The Society for Healthcare Epidemiology of America. The study shows that passive devices that require no user activation are associated with the lowest risk of needlestick injury.

About the Author

Laura Thill
Laura Thill is a contributing editor for The Journal of Healthcare Contracting.