New OSHA directive will cite hospitals for reuse of blood tube holders
February 1, 2002 5 minutes read
New OSHA directive will cite hospitals for reuse of blood tube holders
Directive clearly prohibits common practice
Hospitals that reuse blood tube holders risk getting a citation from the U.S. Occupational Safety and Health Administration (OSHA), according to a new directive issued to inspectors. While the reuse of tube holders is commonplace at hospitals around the country, OSHA clearly prohibits the practice in the compliance directive released in late November. "Some sharps containers have unwinders that are used to separate needles from reusable syringes or from reusable blood tube holders. The use of these [is] generally prohibited," the directive states.
OSHA allows an exception if a medical procedure requires needle removal, but states that any removal must be accomplished in a safe, one-handed manner. "If this situation is encountered, the compliance officer should determine if the circumstances warrant needle removal," the directive states. If they do not, paragraph (d)(2)(vii)(A), which prohibits needle removal unless no alternative is feasible or it is required by a specific medical procedure, should be cited," the directive states.
With the new language, OSHA will begin enforcing a long-standing prohibition. While the 1991 bloodborne pathogens standard states that needles should not be removed unless medically necessary, OSHA inspectors previously had not issued citations for the practice. (See Hospital Employee Health, August 2001, "Watch out! OSHA may crack down on reuse of blood tube holders.") The compliance directive provides guidance to inspectors on the revised bloodborne pathogens standard. The revisions were required by the Needlestick Safety and Prevention Act of 2000 and became effective April 18, 2001.
"I think there should no longer be any question that we can’t reuse the blood tube holders," says Cynthia Fine, RN, MSN, CIC, infection control practitioner at John Muir Medical Center in Walnut Creek, CA.
Needle safety experts lauded the clarification. Earlier this year, Advances in Exposure Prevention (AEP), the publication of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville, highlighted the case of a nurse who contracted hepatitis C after being exposed to the back end of a needle.1
With that article, the center stated that "we think the practice of removing reusable blood tube holders definitely exposes health care workers to additional risk and should be prohibited," says Jane Perry, AEP editor and the center’s director of communications.
To comply, hospitals must cope not only with the increased cost of single-use tube holders, but with a substantial increase in waste. That will require larger sharps disposal containers, Fine notes. "That has been the issue for many, many hospitals. They felt it was safe. They were using the mechanical device for removing the needle and thereby decreasing waste."
Citations for safety devices?
In yet another new area of scrutiny, the 2001 compliance directive leaves an opening for OSHA inspectors to cite hospitals for using inadequate safety devices.
OSHA removed language from the 1999 compliance directive that said, "[the agency] does not advocate the use of one particular device over another." This directive essentially requires health care facilities to use needleless IV systems and plastic — as opposed to glass — capillary tubes by stating, "Where engineering controls will reduce employee exposure either by removing, eliminating, or isolating the hazard, they must be used."
Further, the directive lists design features published by the Food and Drug Administration (FDA), including a recommendation that "the safety feature should allow or require the worker’s hands to remain behind the needle at all times." Older designs that require two-handed activation could be considered unacceptable by an OSHA inspector, Fine notes. "I think certainly the potential is there for citations for that type of device," she says.
The OSHA directive is clear on one point: Hospitals must evaluate new safety technology every year and document that evaluation in the updated exposure control plan. "They want health care facilities to be continuing to update their plans to reflect the changes in technology," Perry says. "They shouldn’t just implement one device and not be evaluating new devices as they come out. The safety device market is continually improving and coming out with new designs." If OSHA inspectors believe a hospital should be using a more effective device, they are directed to document their finding and consult with the regional bloodborne pathogens coordinator "to determine if a violation exists."
The compliance directive offers details on what should be in the exposure control plan, how inspectors will gauge employee input into device evaluation, and what inspectors expect from training programs. Here are some other items inspectors will consider:
• Agency and part-time workers: The hospital must comply with the standard and also must ensure that the agency has followed the standard, including hepatitis B vaccination, post-exposure evaluation and follow-up, record keeping, and "generic training." Students are not covered "if they are not also considered employees," the directive states.
• CDC guidelines: The directive incorporates the Centers for Disease Control and Prevention (CDC) guidelines on post-exposure prophylaxis, which means that OSHA inspectors could cite facilities for failing to follow the guidelines. However, the section on hand antisepsis actually conflicts with new draft hand-hygiene guidelines from CDC. The agency recommends the use of alcohol-based rubs, while OSHA states that employees should wash their hands with soap and water after removing gloves. (See "Make a revolutionary’ change in hand hygiene" in this issue.) "I’m very definitely planning on following the hand antisepsis guidelines as closely as I can," says Fine, noting that she would justify her practice for an OSHA inspector.
• Employee input: OSHA inspectors will ask employees from different departments whether their input was solicited in the evaluation of devices. "The fact that some employees have not provided input does not automatically mean the employer has not solicited input, but should prompt the compliance officer to thoroughly investigate whether input was solicited," the directive states.
In general, the directive helps clarify how inspectors will interpret the revised standard, says Fine. But it won’t answer all questions. "There are still so many interpretations from OSHA compliance officers," she says. Her advice: If inspectors have issued citations at a hospital in your area, "check with those hospitals and find out what the compliance officers said."
(Editor’s note: A copy of the compliance directive is available on line at www.osha-slc.gov/OshDoc/Directive_pdf/CPL_2-2_69.pdf.)
Reference
1. Perry J. When home is where the risk is. Advances in Exposure Prevention 2000; 5:25,30-32.
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