Injury Prevention
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| To achieve the ultimate goal of reducing sharps-related injuries, hospitals need to undertake a series of incremental organizational steps. These steps range from developing organizational capacity to address sharps injuries to assessing processes and identifying intervention priorities. Following the CDC’s model on developing action plans as well as monitoring program performance and improvement are essential for optimal results. |
It has been more than 20 years since the first case of occupational HIV transmission through a percutaneous injury was reported in the New England Journal of Medicine. In the ensuing years, several additional cases that occurred through similar exposures followed.
As of 2006, the Centers for Disease Control and Prevention (CDC) has reported 57 documented and 140 possible cases of HIV transmission to health care personnel. The majority of known seroconversions occurred through a percutaneous exposure (e.g., needlestick). The early cases of occupational HIV transmission were the catalyst that drew attention to the issue of occupational blood exposures and led the Occupational Safety and Health Administration (OSHA) to issue its Bloodborne Pathogen Standard (29 CFR 1910.1030) in 1991. Ten years later, on Nov. 27, 2001, OSHA revised its Enforcement Procedures for Occupational Exposure to Bloodborne Pathogens (CPL 2-2 69) and incorporated new sharps injury prevention requirements.
Key strategies used to prevent HIV and hepatitis B and C virus risks to health care personnel are hepatitis B vaccination, development and use of sharps injury prevention devices, injury prevention behaviors, use of barriers to prevent blood and body fluid contact and, when indicated, the use of post-exposure prophylaxis.
Integral to understanding how to reduce the risk of sharps injuries are the surveillance systems developed for recording and analyzing data on occupational blood exposures, including EPINet, developed by the International Healthcare Worker Safety Center at the University of Virginia, and CDC’s National Surveillance System for Healthcare Workers (NaSH), which is part of the Web-based National Healthcare Safety Network (NHSN).
These surveillance data show the complexity of factors that affect the risk of a sharps injury, including type of device and the circumstance and environment in which each injury occurs. They also show that preventing these events is complex. It has become abundantly clear that it takes more than the use of safer devices, disposal equipment and injury-prevention behaviors to reduce the incidence of sharps injuries. Because of that fact, leadership should be driving an organizationwide approach toward prevention.
In the last few years, other priorities have dominated the attention of health care organizations. Among them are preparedness planning for pandemic influenza and bioterrorism, prevention of multidrug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) and public reporting of health care-associated conditions, including health care-associated infection (HAI). A decline in published literature on sharps injury prevention and updates on the analysis of surveillance data reflects the shift in priorities. However, sharps injuries have not disappeared, and there is an ongoing need to refocus attention on the prevention of this occupational hazard.
A systematic approach
In 2004, the CDC launched A Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program (www.cdc.gov/Sharpssafety). The workbook presents a model program for sharps injury prevention that is designed for integration into ongoing performance improvement activities and processes in any health care organization. It was revised in 2008, but the model program remains at the core, incorporating a multidisciplinary leadership team that includes senior-level management and front-line health care personnel. Key to the success of the program is the involvement of infection prevention/control, occupational health, patient safety, materials management/value analysis leaders and others. As with other performance improvement programs, a series of incremental organizational steps are necessary to ensure that an effective program is established and maintained. Some of the steps can be undertaken concurrently. However, in the end, one builds upon another and each is necessary to achieve the ultimate goal.
Step 1
Develop organizational capacity
Whether a health care organization is revamping a program or starting anew, an organizational structure with defined leadership, authority and responsibility is necessary for any performance improvement program to function effectively and efficiently. The following are diverse contributions that can help a sharps safety team prevent injuries.
Staff contributions/strengths, administration/senior management
- Communicate the organization’s commitment to worker safety.
- Allocate personnel and fiscal resources to meet program goals.
Infection prevention and control/health care epidemiology
- Apply epidemiologic skills to the collection and analysis of data on injuries and health care-associated infections.
- Identify priorities for intervention based on disease transmission risks.
- Assess infection control implications of engineered sharps injury prevention devices.
Occupational health and safety/industrial hygiene
- Collect detailed information on reported injuries.
- Assist in surveying health care personnel on underreporting.
- Assess environmental and ergonomic factors contributing to sharps injuries and propose solutions.
Risk control/quality management
- Provide an institutional perspective and approach to quality improvement.
- Help design processes related to the sharps injury prevention program.
In-service training/staff development
- Provide information on current education and training practices.
- Identify training needs and discuss the organizational implications of proposed educational interventions.
Environmental services
- Provide insight on environmental injury risks not captured through percutaneous injury reporting.
- Assess the environmental implications of proposed interventions.
Central service
- Provide insight into unique injury risks associated with reprocessing sharp devices.
- Identify logistical issues involved in implementing devices with sharps prevention features.
Materials management/value analysis
- Help identify products and manufacturers of devices with engineered sharps prevention features.
- Provide cost data for making informed decisions.
Labor
- Promote injury reporting and safe work habits.
- Promote the implementation of prevention priorities among members.
Front-line clinical and laboratory staff
- Provide insight into injury risk factors and the implications of proposed interventions.
- Actively participate in the evaluation of prevention interventions.
Step 2
Assess program operation
An assessment for the presence and effectiveness of each of these processes is an important program development building step. Of all the steps in building a sharps injury prevention program, this is the most important, but initially is the most labor intensive. A thorough assessment of each of these five program processes will provide the most comprehensive view of the organization’s current capacity to prevent sharps injuries among its health care personnel.
Tips for assessing processes
• The influence of creating a safety climate for patients and health care personnel is broadly recognized and permeates all aspects of health care delivery from preventing falls and medical errors to injury prevention. Health care personnel know when they are working in an environment where safety is valued as there is a shared commitment to safety on the part of senior administration, management and front-line personnel. Among the ways the presence of a safety climate for sharps injury prevention is reflected is in how an organization 1) encourages and facilitates sharps injury reporting, including near-misses, addresses risks once they are identified in a nonpunitive approach to the process and, 2) promotes the evaluation and implementation of safer technologies.
• All health care organizations have some process in place for reporting and recording information on occupational injuries and exposures. To be useful, information on sharps injuries (or near misses) requires sufficient detail so that the type of device involved, the procedure for which it was being used, and the stage in handling the device when the injury occurred (i.e., during or after use, during disposal) is recorded, preferably using a form that will facilitate data entry and analysis.
• The analysis of sharps injury data, be it information on just a few incidents or from a large data set, helps organizations target priorities for intervention. For example, knowing whether injuries are associated with particular devices, procedures or circumstances and even occupational groups, can help focus initial and ongoing prevention efforts. While a common goal is to eliminate all sharps injuries, realistically, an organization must have a starting point for initiating changes that will have the greatest impact.
• The process of selecting sharps injury prevention devices provides health care organizations with a systematic way to identify devices that will best meet their needs. Those selected must be acceptable for patient care as well as provide optimal injury protection for workers. An important aspect of this process is involving the end users of a device under evaluation so that their clinical needs are fully understood.
• The process for educating and training health care personnel who use or may encounter sharp devices in the work environment is another important aspect of a sharps injury prevention program. Educational efforts should encourage awareness that an injury hazard is present throughout the use of a needle or other sharp devices and that health care workers must use injury prevention behaviors from the moment they encounter a patient. Training is equally important; health care personnel who perform procedures that involve use of a sharp device, including the use of devices with safety features, must have time to become familiar with how the procedure is performed and how to avoid injury during the procedure.
Step 3
Baseline profile of injuries and prevention activities
During this phase, an organization steps back, looks at the “big picture” and develops a perspective on what has been done in the past and what needs to be done in the future. Organizations are often surprised at the efforts that they already have in place to protect health care personnel such as the widespread use of sharps disposal containers and bloodborne pathogen education. A number of probing questions about who is at risk of injury, why and what type of interventions should be considered, including safer devices, additional training, communication tools, and/or changes in policies or procedures will help determine direction for the next organizational steps.
Step 4
Identify intervention priorities
From an injury perspective, prevention priorities may be based on the frequency of injuries associated with a particular device or procedure; the risk of bloodborne pathogen transmission such as that associated with hollow-bore blood-filled needles (e.g., needles used for phlebotomy) or observations that injuries during handling or associated with disposal are a more pressing problem. Each organization’s unique injury profile will dictate the priorities established.
Step 5
Develop and implement action plans
The CDC model presents two types of action plans; one for implementing and measuring interventions to reduce or eliminate specific types of injuries, the other for improving the program processes as described in Step 2. These plans can be simple or complex, depending on the nature of a given problem and the requirements for change.
The action plan for reducing or eliminating injuries should specify which injuries are targeted for intervention, the intervention(s) used, how performance will be measured and timelines and responsibilities for implementation. In developing this action plan, among the strategies to be considered are:
- Eliminate unnecessary needle use.
- Implement a needle device with an integrated sharps injury protection feature.
- Implement a change in work practice.
- Change a policy or procedure.
- Provide education or training of health care personnel.
The action plan for improving program processes should focus on system problems identified. Examples of areas that may need to be addressed are injury reporting, data analysis, communications, education and safety climate or culture. This action plan also should have clear, measurable objectives, timelines and responsibilities.
Step 6
Monitor program performance improvement
This is the “continuous” part of performance improvement and most important step for ensuring that the program is sustained. If the program objectives are clear and measurable, then the ongoing process of checking and rechecking progress should be easy. Key measurement(s) should be selected with leadership for reporting progress and improvement to the organization and ultimately to the board (e.g., as part of the organization’s quality scorecard). Changes, whether reductions in injuries or improved compliance with education, must be accompanied with a brief analysis for why the success or setback occurred. This step is critical in maintaining an organizational awareness of occupational safety affecting both patients and health care personnel as well as ensuring ongoing financial support for continuous improvement in minimizing bloodborne pathogen exposure risks.
Summary and resources
Despite the current media attention on HAIs such as MRSA and C. difficile, organizations cannot afford to presume that bloodborne pathogen exposures in the workplace have been solved and let up on strategies to reduce occupational risks. As seen with recent attention and consequences of the improper use of needles and syringes in an outpatient setting, the boundaries have moved beyond the hospital setting to clinics, offices and even homes. Maintaining expertise and sharing lessons learned in the hospital can assist others, but organizations must not let down their guard even as they provide leadership to others. One single HIV infection may be a life never recovered.
Recently, the 2008 edition of the CDC Workbook and other resources on sharps injury prevention, including brochures and posters for health care worker education and training, were made available through Premier Inc. (www.premierinc.com/safety/topics/needlestick). This Web site now provides the most comprehensive consolidated resource on the general topic of sharps injury prevention.
Linda Chiarello, R.N., is a consultant based in Naples, Fla. Both she and Judene Bartley, clinical consultant for Premier’s Safety Institute, collaborated on the 2004 CDC Workbook.