Needlestick prevention legislation is spreading rapidly nationwide
April 1, 1999 9 minutes read
Needlestick prevention legislation is spreading rapidly nationwide
Bills filed in eight states, slated in 10 more as union tries to bypass OSHA
The tide appears to be turning swiftly in the controversial struggle to implement needle safety devices in the nation’s health care settings, as 18 states are following California’s lead and considering laws designed to prevent needlesticks and bloodborne infections. With lawmakers emboldened by California’s landmark 1998 law, needle-safety bills have been introduced in eight states and are under discussion in 10 others and the District of Columbia, according to health care worker union lobbyists. (See box, p. 46.)
For example, on Feb. 4, 1999, lawmakers in the Maryland General Assembly in Annapolis introduced HB 287 (the Health Care Workers’ Safety Act), which calls for state labor officials and representatives from hospital and health care worker groups to work together in evaluating the devices and consider requiring them in state health care facilities. While debate still is under way, opponents will have a hard time dismissing the legislation as an uninformed or unwelcome intrusion into medical practice. Its chief sponsor has another job when not serving in the state House of Delegates: physician in internal and emergency medicine.
Is this the day that I’m going to get stuck?’
"I go to work every day, and I think, is this the day — despite my best efforts to take every precaution possible — that I’m going to get stuck and my life is going to change?" says Dan Morhaim, MD, 11th District delegate and a clinician at Sinai Health System in Baltimore. "I worry about it for me; I worry about it for my colleagues. I don’t think there is a health care worker who works in these kinds of settings that doesn’t think about it at least once a day."
Indeed, Morhaim makes the kind of moral and ethical appeal for action on the long-discussed issue that appears to carry more political currency than health care industry arguments about the lack of clinical data on some of the devices or the exorbitant cost to implement them.
"I’m married, I have kids, and I want to stay healthy," he tells Hospital Infection Control. "I don’t want to have an inadvertent needlestick, and I don’t want to [stop taking] care of people. I’ve seen what other people go through — my colleagues when there is a needlestick — and I’ve certainly met a few people who have contracted serious diseases. I’m willing to accept it if I get stuck by a needle, but I don’t want to be looking at it, thinking this could have been prevented if I would only have had one of those safety [devices.]
Morhaim concedes some of the arguments against blanket adoption of the devices have merit, but emphasizes that clinical situations where needle-safety devices would be inappropriate are rare. For example, a dermatologist recently told the lawmaker that the size and angle of use needed for small intradermal skin-testing needles does not lend itself to safety designs like retractable sharps.
"He may have a legitimate point," Morhaim says. "You always have to acknowledge that there will be exceptions, but the bulk of the work done by the bulk of the people — doctors, nurses, physician assistants, paramedics, technical staff — is very well suited to these new technologies. They ought to be applied to them as soon as possible."
A bump in the road could prove deadly
For example, automatically retractable needles are needed by paramedics trying to administer subcutaneous medication en route to the hospital, he notes. "You go over a bump and the needle goes into your leg," he says. "A retractable needle is ideal for a situation like that."
Emphasizing that he is an advocate of hospitals, Morhaim notes that implementing needle safety is consistent with the broader health care mission of medical facilities.
"I’m just trying to redirect it a little bit in this regard," he says. "Certainly, [hospitals] will come to understand — though they have concerns about costs and protocols — that this is something they are going to need to move into. But I don’t think it was on their radar screen as a project they can undertake without a law. They need a law to do this."
The state legislative action is part of the Washington, DC-based Service Employees International Union (SEIU) "grass-roots" campaign that was outlined recently in a teleconference with members of the press. Speaking in support of the campaign was Lorraine Thiebaud, RN, a registered nurse for 25 years, who said it was seeing colleagues infected by needlesticks that led her to fight for sharps safety devices at San Francisco General Hospital and then lobby for passage of California’s needle-safety law.
"This law in California will drastically reduce the number of needlestick injuries so California health care workers can go to work without fear of contracting a deadly disease," she says. "But this legislation needs to be passed in every state. We know from our awful experience that safer needles will not be in workers’ hands if it is left up to hospital administrators and needle manufacturers."
An ICP from Wisconsin — one of the states where legislation is expected to soon be introduced — says she would support a law similar to that passed in California. "I would welcome the day," says Rita McCormick, RN, CIC, infection control practitioner at the University of Wisconsin Hospital and Clinics in Madison. "Way too much time has elapsed between the onset of the HIV pandemic and finally getting to the point of where the real risk is [for health care workers]."
But for many ICPs, who often are charged with evaluating and implementing the devices at facilities making such transitions, the issue can prove thorny. Efforts to contain costs and implement only the most appropriate and effective devices can lead them to the slippery slope of seeming to be insensitive to worker safety. On the other hand, individual ICPs working actively to implement the devices may struggle to justify the expenditures to tight-fisted financial officers and administrators. Moreover, even successful needlestick reduction programs like that recently described at the Mayo Clinic report some problems getting workers to accept the new equipment and abandon conventional needles.1 (See Journal Review, p. 54.)
For its part, the Association for Professionals in Infection Control and Epidemiology (APIC) initially strongly questioned "the one size fits all" aspects of the California regulation and warned against adopting provisions that would restrict health care professionals from the best practices in their individual facilities. More recently, APIC refined its national position to a more conciliatory call to target the highest-risk injuries in implementing needle safety devices.2 (See HIC, September 1998, p. 132; February 1999, p. 21.)
"I was surprised at the reaction of the infection control practitioners to the initial California legislation," McCormick says. "They hadn’t, from my perspective, looked at the big picture and thought it through. It’s the right thing to do."
Though not a union member, McCormick says the SEIU grass-roots state campaign was probably born out of a frustration she can empathize with.
"Their strategy isn’t bad, but why have all these local laws if you could have a federal [law]?" she asks. "From my perspective, that is the preferred way to go, because irrespective of what state you live in, you would have the benefit."
A twofold strategy
Indeed, SEIU president Andrew Stern agreed at the aforementioned media conference that a federal law would be preferable and will continue to be pursued. However, he reiterated the union’s concerns that the Occupational Safety and Health Administration (OSHA) is moving too slowly with its recent request for information on the issue, though many observers consider the agency’s move a prelude to regulatory action.3 While the grass-roots state-by-state effort can be seen as an attempt to make an end run around a plodding federal bureaucracy, the campaign also may increase awareness and discussion at the state level, thus leading to calls for a federal standard.
"We totally agree that a federal standard is the ultimate solution," Stern says. "We have called upon the producers of needles and other members of the health care community to join with us in either getting OSHA to establish a national standard or [to] pass federal legislation."
The California law — which essentially requires implementation of the devices unless clinicians can cite one of four narrowly drawn exceptions — is being used as an example of model legislation in union lobbying efforts within other states. In that regard, Stern cited a recent Cal-OSHA report, prepared to assess the impact of the regulation in California, that determined that the state health care industry will save more than $100 million a year by using safer needles. However, the Cal-OSHA cost-savings claim and the figures used in its analysis are being labeled as highly inaccurate by some. (See related story, p. 48.)
Other states considering similar laws should be aware that compliance efforts are expected to be expensive, rather than a cost savings, says Roger Richter, senior vice president of professional services at the California Healthcare Association.
"It’s just fair that people know that this is not a cost savings," he tells HIC. "It is going to be a major expense. In today’s health care field, it is not just an add-on. What it means is that something else may have to go in place of it. That doesn’t downplay the importance of sharps injury prevention, but in no way — at least at this time, with the expensive devices that are out there — is it a cost savings."
Asked about concerns that hospitals may try to meet the cost increases in the short term with budget cuts in other areas, Stern says such spec ters are typically raised whenever employers are pressured to spend more for worker benefits and safety.
While noting that needle-safety devices are currently in the range of three to four times more expensive than conventional needles, Morhaim says the actual and intangible cost benefits of preventing bloodborne infections and eliminating time-consuming and stressful follow-up testing of health care workers also must be factored in.
"Ultimately, I don’t buy the cost arguments," he says. "[But] California, because of its size and marketplace power, is going to redefine the marketplace. I think we can gain from that as well."
McCormick concurs, noting, "There isn’t any question in my mind; this is all going to go the way of calculators. They used to be very, very expensive, and now you pick them up for pennies."
Indeed, an executive with a needle-safety device manufacturing firm says the California law has changed the business equation, finally clearing the way for economies of scale to develop by ensuring all manufacturers there is a market large enough to justify mass production of the devices.
"One of the things that has been a dilemma for the manufacturers of needle devices is the uncertainty looking forward of how much of the market is going to be standard needles vs. safety needles," says Tom Sutton, MBA, vice president of Bio-Plexus Inc. in Tolland, CT. "The more clarity and certainty there is that the market is going to switch to safety devices, the more you can [focus] your forward planning on safety designs. Right now, there is a lot of risk in the early investment that has to be captured in the cost. The more the market switches to safety, the faster the prices are going to get shaken down because of competitive forces."
Moreover, the gathering momentum for a widespread transition to needle-safety designs raises product liability issues for manufacturers of conventional devices, he notes.
"As your safety device becomes more and more successful at preventing needlestick injuries, it is difficult to build a case of why you should be able to offer a standard device without a protective feature and also one with a protective feature," he says.
According to traditional business theories regarding the standard product life cycle, safety needles are moving from the introductory stage to the growth stage, and standard needles are in a mature market phase that is losing its longstanding stability, he adds.
"California is the bell in the night," Sutton says. "Everyone should see with clarity that safety is going from an option to a requirement. I think that probably in the next two to three years, standard unprotected needles are going to be seen as obsolete and unduly risky."
References
1. Dale JC, Pruett SK, Maker MD. Accidental needlesticks in the phlebotomy service of the department of laboratory medicine and pathology at Mayo Clinic Rochester. Mayo Clin Proc 1998; 73:611-615.
2. Association for Professionals in Infection Control and Epidemiology. APIC 1997 and 1998 Guidelines Committees. APIC position paper: Prevention of device-mediated bloodborne infections to health care workers. Am J Infect Control 1998; 26:578-580.
3. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: Request for information. 63 Fed Reg 48,250-48,252 (Sept. 9, 1998).
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