Recent changes in federal legislation have helped prevent sharps injuries in healthcare facilities. Congress passed the federal Needlestick Safety and Prevention Act in 2000. This legislation mandated the revision of the 1991 Bloodborne Pathogens Standard to require engineered sharps injury prevention devices whenever possible. The Act also requires employers to maintain a Sharps Injury Log that records the type and brand of device involved in an incident, the work area where the injury occurred, and an explanation for how the injury happened. Employers must also develop a written Exposure Control Plan.
A healthcare worker's risk of infection following a needlestick exposure depends on the pathogen involved, the worker's immune status, the severity of the needlestick injury, and the availability and use of appropriate post-exposure prophylaxis. An employer exposure control plan (ECP) is a requirement of 29 CFR 1910.1030(c) of the Bloodborne Pathogens Standard established by the Occupational Safety and Health Administration (OSHA). The purpose of the ECP is to establish procedures to eliminate or minimize employee exposure to bloodborne pathogens.
A written ECP outlines the strategies necessary to eliminate or minimize employee occupational exposure to bloodborne pathogens. This site-specific plan identifies all employee classifications with occupational exposure to bloodborne pathogens and other potentially infectious materials. Additional components of an ECP include engineering and work practice controls, personal protective equipment, housekeeping, and containment and labeling of potentially infectious materials.
The written ECP must be accessible to all employees. It must be reviewed and updated annually or when alterations in procedures create the possibility of new occupational exposures. Additionally, non-managerial employees who provide direct patient care must be asked to provide input in identifying, evaluating, and selecting effective controls to isolate or remove bloodborne pathogens from the workplace.
An employer's ECP must identify all specific procedures an employee performs which may expose them to bloodborne pathogens.
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The following case report describes the experience of two health care workers who developed severe infections after occupational exposures to bloodborne pathogens. This case illustrates several preventable hazardous conditions and practices that can lead to needlestick injuries.
A hospitalized patient with AIDS became agitated and tried to remove the intravenous (IV) catheters in his arm. Several hospital staff members struggled to restrain the patient. An IV infusion line was pulled during the struggle, exposing the connector needle inserted into the IV catheter's access port. A nurse at the scene recovered the connector needle at the end of the IV line. She tried to reinsert it when the patient kicked her arm, pushing the needle into the hand of a second nurse. The nurse who sustained the needlestick injury tested negative for HIV that day. However, the injured nurse tested HIV positive several months later.
Although sharp devices can cause injuries anywhere within the healthcare environment, most (40%) occur in inpatient units, such as medical floors, intensive care units, and operating rooms. Sharp-related injuries generally occur after use and before disposal of the sharp device (41%), while the sharp device is being used on a patient (39%), and during or after removal (16%).
It is essential to report all sharps injuries and all sharp hazards you observe to your employer. You may help prevent someone else from being injured.
Sharps injuries can happen before, during, or after the use of a sharp. The following are some examples of high-risk activities in a healthcare setting.
During patient care:
Immediately after sharp use:
In hospitals, 80% (4 in 5) of sharps injuries are due to the use of:
You can use many different types of sharps safety devices to protect yourself. Here are a few options:
Employers are required to involve frontline workers in selecting devices with safety features. It is important to choose devices that:
It is necessary to implement work practice and engineering controls to help prevent exposure to sharps. OSHA requires sharps must be appropriately disposed of immediately or as soon as feasible into the appropriate containers. [29 CFR 1910.1030(d)(4)(iii)(A)(1)]
Employees should be trained in the proper handling and disposal of sharps and containers. When moving containers of contaminated sharps from an area of use, the containers shall be:
The risks and costs associated with blood exposure are serious and real in a healthcare setting. Direct costs associated with exposure include the initial and follow-up treatment of exposed healthcare personnel. These can range from $500 to $3,000, depending on the treatment provided. Indirect costs include lost employee productivity and healthcare provider time to evaluate and treat the employee and evaluate and test the exposure source.
Costs that are harder to quantify include the emotional toll associated with fear and anxiety from worrying about the possible consequences of exposure and the cost of any associated litigation.
The National Institute for Occupational Safety and Health (NIOSH) recommends that employers use the hierarchy of controls to prevent sharps injuries. When applying the hierarchy of controls, employers must select the most effective control strategy or method to eliminate or reduce exposure to the hazard. In healthcare, engineering, work practice, and PPE controls are generally the most widely used methods to protect employees from exposure.
While most effective at eliminating or reducing hazards, the elimination and substitution methods can be challenging to implement. These control methods are designed to eliminate a hazard by removing exposure entirely or substituting less hazardous materials. In the healthcare setting, it may not be possible to eliminate exposure to a hazard. Similarly, it may not be possible to substitute a less hazardous material to achieve the same objective. Despite these hurdles, the elimination and substitution methods should be considered when evaluating how to reduce exposure to hazards.
Engineering controls focus on eliminating or reducing the actual source of the hazard. The basic concept behind engineering controls is that the work environment and the job itself should be designed to eliminate or minimize risks. Engineering controls are measures that isolate or remove the workplace's hazard.
Examples of engineering controls include:
Sharps disposal containers are considered an engineering control for sharps injury prevention. These come in various sizes, shapes, and options and should be selected based on the need in each area. Location is key to success, and research shows the closer the container is to the point of use, the lower risk for sharps injuries. Although these containers effectively prevent sharps penetration through the sidewall, overfilling them can provide injury opportunities and, therefore, should be avoided.
These safer needle devices allow a sleeve to slide forward over the needle, locking the guard in place and providing a mechanical barrier around the used needle.
There are many types of safer medical devices. Some examples of these safety devices include:
Work practice controls reduce the likelihood of exposure by altering how a task is performed. The recapping of needles using a one-handed technique is an example of a work practice control. Similarly, passing a needle or other sharps device indirectly to another person would be another example of a work practice control.
Operating room work practice controls should include:
Administrative controls are policies established and frequently used with existing processes where hazards are not particularly well controlled. Administrative control programs may be relatively inexpensive to establish but, over the long term, can be very costly to sustain. These methods for protecting workers have also proven to be less effective than other measures, requiring consistent employee adherence and management monitoring.
Policies that prohibit hazardous sharps handling activities should be implemented and required. Examples of hazardous sharps activities include:
To protect healthcare workers from needlestick injuries, employers must provide a safe working environment that includes safer needle devices and effective safety programs. It is necessary to train healthcare workers in the safe use and disposal of needles and sharps.
As we have already discussed, many types of needle devices are associated with needlestick injuries. These injuries can occur in many ways. Therefore, employers must consider a combination of prevention strategies. Employers should take the following steps to implement a program to reduce needlestick injuries and involve workers in this effort.
Employers should implement the use of improved engineering controls to reduce needlestick injuries. For example:
Employers must also modify work practices that pose a needlestick injury hazard to make them safer. They can help eliminate dangers by changing work practices, which include the following:
To protect themselves and their co-workers, healthcare workers should be aware of the hazards posed by needlestick injuries. They should use safety devices and improved work practices as follows:
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