Special Report: Frontline HCWs
OSHA answers questions on needlestick safety
(Editor's note: The Occupational Safety and Health Administration distributed a question-and-answer needlestick prevention pamphlet at the recent Frontline Healthcare Workers conference in Washington, DC. Highlights of the OSHA material are summarized as follows to assist infection control professionals in education efforts.)
Q: Why do I need to worry about needlesticks?
A: If you're an employer of health care workers who are potentially exposed to blood and contaminated needles, you should know that there are an estimated 800,000 needlesticks each year in the United States, with many more unreported. About 2%, or 16,000 of these, are likely to be contaminated with HIV. Needlestick injuries account for up to 80% of accidental exposures to blood. Nurses in hospitals are the most frequently injured.
Q: When might my employees be injured by a needlestick?
A: Needlestick injuries may occur when employees dispose of needles, collect and dispose of materials used during patient care procedures, administer injections, draw blood, or handle trash or dirty linens.
Q: Isn't there just a small chance of such an injury?
A: Data from 63 hospitals show that the overall rate of such injuries is 27 per 100 occupied beds annually. Nurses had the most frequent exposures (49.7%); physicians ranked second (12.6%); nursing assistants accounted for 5.3%, and housekeepers, 5.1%.1 Hollow-bore needles are the cause of injury in 68.5% of all cases.
Q: What can happen from a needlestick?
A: More than 20 pathogens have been reportedly transmitted from needlesticks.2 The most serious are the transmission of hepatitis C virus (HCV), hepatitis B virus (HBV), and HIV. In fact, the risk of transmitting HBV and HCV is much higher than for HIV.
Q: Why is transmission more likely to be from hepatitis B and C than from HIV?
A: The risk of transmission has to do with the prevalence of these diseases in the patient population at large. For example, an estimated 1.25 million people in the U.S. are chronically infected with HBV, and 6,000 die each year from HBV-related liver disease. HCV also is a major cause of chronic liver disease worldwide. In 1997, there were an estimated four million people in the United States infected with HCV.3 As many as 85% of all HCV-infected people develop chronic hepatitis and are at increased risk for cirrhosis and primary hepatocellular carcinoma.4 Liver failure from HCV is the leading reason for liver transplants in the United States.
Q: So, do I still need to worry about HIV exposures for employees?
A: Yes. The total number of occupationally acquired HIV infections in health care workers continues to increase each year. Of the 52 documented cases in 1996, 45 were from needlesticks or cuts.5
Q: How can I protect employees against potential exposures?
A: Make sure employees use universal precautions, personal protective equipment, and engineering and work practice controls to reduce their exposure to bloodborne pathogens, as required by OSHA's bloodborne pathogens standard.
Q: Can't needles penetrate most personal protective equipment? Are employees still safe wearing gloves?
A: You're correct; most personal protective equipment can be penetrated easily by needles. Most needlestick injuries, however, result from unsafe needle devices rather than carelessness by health care workers. Safer needle devices have been shown to significantly reduce needlesticks and exposures to potentially fatal bloodborne illnesses.6
Q: What's a safer needle device?
A: A safer needle device has built-in safety controls to reduce needlestick injuries before, during, or after use and to make needlesticks less likely.
Q: Will these devices prevent needlestick injuries?
A: Not all needlestick injuries are preventable, but using devices containing needles with built-in safety features or other devices that eliminate the use of needles altogether can reduce the number. Using needleless IV connectors, self-resheathing needles, or blunted surgical needles, for example, can help reduce the risk of injury. In fact, almost 83% of injuries from hollow-bore needles are potentially preventable.1
Q: How do these devices work?
A: In general, properly designed devices should:
· provide a barrier between the hands and the needle after use;
· allow or require the worker's hands to remain behind the needle at all times;
· have safety features integral to the device itself rather than as accessories;
· be in effect before disassembly and remain in effect after disposal to protect downstream workers;
· be simple and easy to operate, with little or no training;
· and not interfere with the delivery of patient care.
Q: Are there specific safety features I need to know about?
A: Yes, that would be helpful. For example, it is good to know whether the feature is active or passive or whether the engineering control is part of the device. Types of safety features include the following:
· Passive safety features remain in effect before, during, and after use; workers do not have to activate them. Passive features enhance the safety design and are more likely to have a greater impact on prevention.
· Active devices require the worker to activate the safety mechanism. Failure to do so leaves the worker unprotected. Proper use by health care workers is the primary factor in the effectiveness of these devices.
· An integrated safety design means the safety feature is built in as an integral part of the device and cannot be removed. This design feature is preferred.
· An accessory safety device is a safety feature that is external to the device and must be carried to, or temporarily or permanently fixed to, the point of use. This design also is dependent on employee compliance, and according to some researchers, is less desirable.
Q: Does OSHA require these devices?
A: No. OSHA does not require employers to institute the most sophisticated engineering controls, but it does require that they evaluate the effectiveness of existing controls and review the feasibility of instituting more advanced engineering controls. Further, OSHA's bloodborne pathogens standard requires that employers establish a written exposure control plan as well as engineering and work practice controls to eliminate or minimize employee exposure.
Q: What steps do I need to take to have a comprehensive prevention program and to implement safer needle devices?
A: As an employer of health care workers, you have the flexibility to develop individual work site-specific needlestick prevention programs to protect employees. Such a program would mean you have a mechanism in place to select and evaluate safer medical devices in a systematic manner. In evaluating safer needlestick devices, ideally you should evaluate your workplace and base your choices for these types of products on the needs of the primary users and the patients. Patients must continue to receive safe, efficient, and comfortable care. Workers are likely to reject products they think will interfere with patient care in any way.
In addition, a comprehensive needlestick prevention program might include the following:
· Creating a multidisciplinary team to investigate and assess needlestick incidents.
· Defining prevention priorities on the basis of collection and analysis of an institution's injury data.
· Developing design and performance criteria for product selection according to needs for patient care and health care worker safety.
· Planning and implementing an evaluation of products in clinical settings.7
References
1. Ippolito G, Puro V, Petrosilo N, et al. Prevention, Management & Chemoprophylaxis of Occupational Exposure to HIV. Charlottesville, VA: International Health Care Worker Safety Center; 1997.
2. Chiarello L, Nagin D, Laufer F. Pilot Study of Needlestick Prevention Devices. Report to the Legislature. Albany, NY: New York State Department of Health; March 1992.
3. U.S. Department of Health and Human Services, National Institutes of Health. Consensus Development Statement: Management of Hepatitis C. Available on-line at http://odp.od.nih.gov/consensus/statements/cdc/105/105_stmt.html. 1997.
4. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 88(2), 1996.
5. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention. HIV/AIDS Surveillance Report. 8(2): Atlanta, 1996.
6. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance Report. 9(1): Atlanta, 1997.
7. Chiarello L. Selection of safer needle devices: A conceptual framework for approaching product evaluation. Am J Infect Control 1995; 23:386-395.
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