National petition renews focus on sharps injury prevention techniques
Lag time between support and implementation
A recent petition by the Carlsbad, CA-based National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI) asking for a new "Notification to Clinicians on Sharps Injury Prevention" has once again shone a bright light on the importance of preventing needlestick and other sharps injuries. In addition, the petition, which was addressed to the National Institute for Occupational Safety and Health (NIOSH), brings attention to the recent progress that has been made in this all-important area.
But NAPPSI’s rationale for the petition was more than a call to action, says Brad Poulis, MBA, the organization’s executive director. It was a definitive statement of the group’s overriding philosophy and mission. "No. 1, NIOSH is probably the top target in terms of the organizations that are more capable of informing and communicating to health care workers on various safe practices," he notes. "No. 2 is timeliness. The wording NIOSH currently uses is over 10 years old and does not truly incorporate the concept of primary and secondary prevention."
At the time of early needlestick safety awareness that accompanied the rise of AIDS in the late 1970s and early 1980s, there was a major focus on bloodborne pathogens, Poulis notes. "People wore gloves, facemasks, and increased their needlestick injury awareness," he says. "Using engineering controls was the thing: find something that can keep sharps from sticking you."
What NAPPSI would like to see, he says, is a greater emphasis on primary prevention, which involves the elimination of needles. "Obviously, NIOSH says you should use needleless systems wherever possible, but the key is to exhaust all primary prevention items and then use secondary prevention," he says. "We’re also asking NIOSH to put these in the front of their guidelines. If you go to their site now and try to find this information, you have to dig pretty deep."
Primary vs. secondary prevention
A number of health care professionals agree that primary prevention is preferable. "God, yes, needleless techniques are the best," says Jean Randolph, RN, COHN-S, employee health manager for Children’s Healthcare of Atlanta, and a member of the national board of directors of the Atlanta-based American Association of Occupational Health Nurses (AAOHN). "I’m on 24-hour call for needlestick injuries. I’m praying for [needleless technology]."
But that support is not universal, says Steve Bierman, MD, CEO of San Diego-based Venetec International. Bierman is NAAPSI’s founder and president. "I was an emergency doc for 18 years, so my roots are in the acute-care setting," he explains. "I know from that and from other experience that if you go to an occupational health nurse or a needlestick prevention nurse they will feel they have done their job by shielding, sheathing, or retracting the needles that are in the workplace."
Part of the reason for this, he says, is the focus of the needle manufacturing industry, which is spending "enormous marketing dollars" on their safety devices. "The lion’s share of health care workers has quite naturally migrated to that kind of safety product, namely secondary prevention," Bierman says. "But while NAPPSI and Venetec applaud Becton Dickinson and Johnson & Johnson for making needles safer, the safest needle is the needle that never enters the workplace. Thus, primary prevention is always superior when it can be employed. Of course, when you absolutely have to have a needle enter into the patient’s skin, secondary prevention is absolutely necessary."
The number of needleless options available is growing almost daily, says Poulis. "New technologies come out all the time," he says. "Probably one of the most important functions we provide is education. I get calls almost weekly asking what is available. One of the problems is that some of the companies that offer them are fairly small and don’t have much money in their marketing budgets. Not everyone is aware these products even exist."
Some needleless options
Needleless options fall into several different categories, says Poulis. They include:
• Needless injection systems: These devices mostly use forced air with micronized vaccine or medication delivery ."A big focus is on commonly injected systems like flu and other vaccines, as well as insulin," says Poulis. "Use of these systems would also contribute to eliminating a large amount of medical waste, which would help protect waste workers as well."
• Hemodynamic monitoring: This includes noninvasive monitoring of blood and heart/cardio functions. "You would use a central venous catheter, already common in the [intensive care unit], with electrical impulses giving you the information you need," Poulis says. "There are devices out there now, using little adhesive pads on the chest that take the measurements without piercing your body."
• Securement devices: These replace sutures for anchoring various catheters by using adhesive pads with anchors.
• Needleless diagnostics: One such option is called the lassette, which uses a laser beam to put a small hole in the finger to check blood sugar. "This is currently on the market," says Poulis.
• Needleless intravenous (IV) products: These would allow health care workers to access IV lines without a needle.
• Surgical glues and adhesives: There is a new product by Ethicon called Dermabond that is a skin adhesive for mild, sharp cuts such as knife cuts. "This can be used instead of stitches," Poulis explains.
• Nontraditional drug delivery: This includes nasal inhalants and patches. "The challenge here is to create formulations with drugs that can be delivered through nontraditional methods," Poulis notes.
The value of primary prevention can be seen, says Bierman, when one looks at extension sets. "If at one end you have a needle-free valve, like Baxter’s Clearlink, then in order for access you don’t need a needle, just a syringe," he notes. "If at the other end you have a catheter securement device instead of tape or suture, then because you will be reducing unscheduled restarts by 71%, the needle you would have had to use for a restart is no longer necessary.
"So, if you put these devices on both ends of an extension set, you eliminate the majority of needles used in IV therapy," he continues. "We believe this would eliminate 100 million needles a year from the hazard string. There’s not a hospital in the U.S. with less than 50% unscheduled restarts, and health care workers use the most dangerous of all needles — the hollow-bore needles."
The secondary prevention debate
Secondary prevention devices, where the sharp is in place but it is rendered safer, are available for many different applications, such as blood drawing devices, IV catheters, syringes, and scalpels. "There is a whole plethora of products that shield the needle in one form or another," notes Poulis.
The raging debate, he says, is which type of shield is preferable. "It comes down to active vs. passive," he explains. "Take a syringe. If after you do an injection you push a button and the needle then pops back into the tube, this is an active’ technique, because you have to push the button. With a passive device, as you are pulling the needle out, a little sheath automatically comes over the needle and clicks into place. You can’t stop it. That’s considered passive." Some health care professionals criticize the passive devices because they can sometimes affect clinical technique, says Poulis.
Bierman, however, sees it a bit differently. "Anything is better than nothing, and I applaud any institution that adopts either approach," he says. "But because nursing staffs change so frequently, it’s very difficult to train and cross-train everyone. That being the case, I incline toward a passive technique because there’s less of a teaching burden."
Randolph agrees. "I like the passive approach because you don’t have to go through a lot of training," she says. "The only reason you would have to stick the patient again is if you don’t have any idea how to use it. But the highest probability is that you will have emptied the syringe or gotten the IV catheter in before you retract the needle. The only chance for an accident is if the technology is faulty."
Easier said than done?
The main challenge in the move towards needleless techniques, Randolph maintains, is not a lack of support but a cumbersome regulatory process. "My sense is we’re all working on this. It’s an absolutely wonderful idea to go to safe needles, or to no needles. But I don’t think anybody has any idea what kind of job this entails," she says. Randolph knows whereof she speaks; she sits on her institution’s committee to examine potential new techniques and equipment in this area. "We are required by OSHA to bring these devices into the hospital, evaluate them, and have 50% of the users responding by filling out the evaluation." So, for example, if the product is an IV catheter, the nurses are trained on it by representatives from the manufacturer. Then they use it, but they still have to complete the evaluation.
"We don’t have enough nurses as it is," notes Randolph. "Now, we want to give them forms to fill out. We have to distribute the devices, train the nurses, and get the evaluations back. This is not a process that lends itself to any kind of speed." Nevertheless, she says, some of the new devices have successfully made inroads. "In most hospitals, extension sets are darn near a given," she says. She notes recent improvements in securement devices, which she considers "a real important piece" in the move to improve sharps safety. "Some people stay in the hospital for a day or two and then go home with lines," she observes. "Securement devices are really important then, because you don’t have anesthesiologists or IV therapy nurses right there."
Randolph adds that "It’s crazy to think health care systems do not want needleless solutions, because every stick is a potential HIV case. The cost of that is phenomenal, and besides, think of the impact on someone’s life."
Bierman couldn’t agree more. "I don’t want to see another doctor or nurse get hepatitis B or HIV, and die from an unnecessary needlestick," he says. Bierman notes that NAPPSI will print an advisory on its web site (www.nappsi.org), and will be asking Journal of the American Medical Association and major nursing journals to include it in future issues. "Our people are overworked," he says. "The danger faced in other hazardous occupations is small potatoes compared to the danger every doctor and nurse face every day; someone turns around and pokes you and you’re done."
For more information, contact:
• Brad Poulis, Executive Director, National Alliance for the Primary Prevention of Sharps Injuries, Carlsbad, CA. Telephone: (858) 350-8623.
• Steve Bierman, MD, CEO, Venetec International Inc., San Diego, CA. Telephone: (800) 833-3895. Web: www.Venetec.com.
• Jean Randolph, RN, COHN-S, Employee Health Manager, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Road, Atlanta, GA 30342. Telephone: (404) 250-5437. E-mail: [email protected].
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