Bloodborne Pathogens Sharps Injuries and Safety Sharps Bloodborne

Bloodborne Pathogens, Sharps Injuries, and Safety Sharps • • • Bloodborne Pathogen Statistics Federal and state BBP regulations Texas sharps injuries Safety Sharps Recommendations

BBP Statistics at a Glance • In 2000, globally an estimated: 36. 1 million persons with HIV/AIDS • In 2000, in US an estimated 340, 00 persons living with AIDS • In 2003, an estimated 1 million persons are living with HIV infection in U. S. • Due the highly active antiretroviral therapy (HAART) since 1996, persons with HIV are living longer and the progression to AIDS has lessened. • Reports of global BBP infections among an estimated 35 to 100 million health care workers is fortunately small in comparison to risk: • 65, 000 Hepatitis B infections • 16, 400 Hepatitis C infections 2 • 1000 HIV infections

U. S. Seroconversion of Health Care Workers • Fifty-seven health personnel in U. S. have been documented to seroconvert to HIV following occupational exposures (with no new cases since 2001) • One hundred and thirty-nine other cases of HIV or AIDS have occurred among health care workers who have not reported other risk factors Source: Department of Health and Human Services, CDC Prevention and Surveillance of healthcare personnel with HIV/AIDS as of December 2002.

BBP Risk With Percutaneous Injury • 0. 3% risk for contracting HIV with device contaminated with HIV • 1. 8% risk for Hepatitis C if device is contaminated with HCV • Hepatitis C is the most frequent infection resulting from sharps injuries • 2 -40% risk for Hepatitis B with contaminated device • Unlike HIV and Hepatitis C in which there is no vaccine, Hepatitis B is preventable with vaccine • Regulations requiring vaccination of health care workers has resulted in the reduction of cases from 17, 000 to 400 annually.

Bloodborne Pathogen Regulations • Title 29 of the Code of Federal Regulations 1910. 1030 • Establish an Exposure Control Plan and update annually • Use universal/standard precautions • Enforce work practice controls-handling of specimens, cleaning, laundry handling, hand washing • Provide HBV vaccine and post-exposure follow-up to any worker with an exposure incident • Use labels and signs to communicate hazards

Title 29 of the Code of Federal Regulations 1910. 1030 cont. • Provide personal protective equipment • Institute engineering controls-sharps containers, safer medical devices • Provide bloodborne pathogen education annually to staff with retention of education records

Needlestick Safety and Prevention Act 2000 Revised the previous Bloodborne Pathogen standard to require: 1. The evaluation and implementation of safer needle devices. 2. Documentation of non-managerial staff involvement in selection of safer devices 3. The establishment and maintenance of a sharps injuries log.

Texas Bloodborne Pathogen Law • Texas State Legislature passed House Bill 2085 that contained Bloodborne Pathogen regulations effective 2001 1. Law to be analogous to federal mandates 2. Applicable to governmental entities not covered by OSHA • To report sharps injuries to state health department • State required to make an aggregate report of the injuries

Texas Bloodborne Pathogen Law • • • Content of Sharps Injury Report Facility and contact person Date and time of injury Age and sex of injured employee Type and brand of device involved Original intended use of device When in the process did injury occur

Sharps Report Content (cont. ) • Was device safety engineered • Glove use, BBP education in past year, sharps container available, HBV vaccine series • Job classification of injured person • Employment status of injured person • Type of worksite where injury occurred • Work area where injury occurred

Texas BBP Law cont. 2006 BBP Rules Amended: Cessation of Waivers for Undue Burden and Rural Counties for not using needless devices and safety engineered sharps

2003 Federal Medicare Law • Center for Medicare/Medicaid Services requirement for facilities (including governmental entity hospitals and clinics) to comply with BBP standard and that fines will be imposed for those who fail to comply • OSHA continues to be inspect works sites and levy fines for non compliance with work place mandates

OSHA Directs Single Use of Blood Tube Holder Risks to health care worker and to patient Clinical studies have shown a 50 -80% contamination of the blood tube holder after one usage

Implementing Laws and Directives Changing from Glass: 1. Plastic Blood Tubes 2. Mylar-Wrapped Capillary Tubes with self sealing Tips that require no pressure 3. Plastic Slides 4. Products that allow the Hematocrit to be measured without centrifuge

Dedicated glucose monitors, insulin vials, and lancets CDC reported transmission of HBV among residents in 3 long term care facilities attributed to shared devices, multi-dose vials, glucose monitors, lancets, and other breaks in infection control practices.

U. S. Sharps Injuries • CDC estimates that there are 385, 000 needle and other sharpsrelated injuries sustained by hospital-based and other healthcare personnel per year • An average of 1000 injuries per day • Inconsistency in Reporting and Profound Underreporting • May be as high as 70% in some facilities Source: CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program

Texas Governmental Entity Sharps Injuries Year 2001 Number of Injuries 1789 2002 2003 2004 1622 1779 1686 2005 2006 1858 1473

Five years of Injuries by Job Title

Sharps Injuries by Facility Over Five Years 19

Type of Sharp At Time of Injury For Five Years

Other Injury Criteria Reported • Gender >60% Female • Area of Injury >90% Hand • Age Group 25 through 34 Highest Percent of Injuries • No Seasonal variation in sharps injuries • Highest number occurred 7 am to 3 pm • Injuries related to sharps container were reduced from 14% in 2001 to 8% in 2005

Work Areas with Greatest Number of Injuries • • Operating Room Patient/Resident Room Procedure Room Emergency Dept Laboratory L&D/GYN Medical/Outpatient 28. 35% 19. 16% 9. 91% 9. 13% 4. 80% 4. 27% 3. 97%

Procedure at Time of Injury • • Injection Suture Skin Draw Venous Blood Suture Deep Cutting Start IV/Heparin Lock Obtain Fluid/Tissue Sample 18. 80% 13. 94% 11. 80% 9. 79% 9. 13% 6. 67% 5. 22%

Types of Sharps Associated with Injuries

Activities Related to Sharps Injuries

Texas Sharps Injuries With Safety Engineered Devices 2001=15% 2002=21% 2003=27% 2004=22% 2005=30% 26

Cost of Sharps Injuries • Medical care ranges from $500 to $3, 000 depending upon the treatment • One serious bloodstream infection can cost an estimated $1 million in direct and indirect costs • Costs are hard to quantify • • • Direct and indirect costs such as drug toxicity Cost of emotional trauma to employee Workers comp. , burden of medical care Societal cost associated with HIV/Hepatitis Cost of any associated litigation

Denominators for Calculating Percutaneous Injury Rates Possible denominators to use: Number of FTE in job classification/yr Number of occupied beds per time frame Number of safety devices purchased in a given time frame [Use 100 for k, Numerator is Number of injuries in specific time frame]

Effects of Implementing Safety Engineered Devices • Comparison study showed: Mean annual Injury Before After Incidence per 1000 FTE 34. 08 14. 25 (P<. 0001)

Selecting and Evaluating Needle Devices with Safety Features • Form a multidisciplinary team that includes workers to: • • develop, implement, and evaluate a plan to reduce needlestick injuries in the institution and evaluate needle devices with safety features. • Identify priorities based on assessments of how needlestick injuries are occurring, patterns of device use in the institution, and local and national data on injury and disease transmission trends. Give the highest priority to needle devices with safety features that will have the greatest impact on preventing occupational infection (e. g. , hollow-bore needles used in veins and arteries). • When selecting a safer device, identify its intended scope of use in the health care facility and any special technique or design factors that will influence its safety, efficiency, and user acceptability. Seek published, Internet, or other sources of data on the safety and overall performance of the device.

• Conduct a product evaluation, making sure that the participants represent the scope of eventual product users. The following steps will contribute to a successful product evaluation: • Train health care workers in the correct use of the new device. • Establish clear criteria and measures to evaluate the device with regard to both health care worker safety and patient care. (Safety feature evaluation forms are available from the references cited earlier. ) • Conduct onsite followup to obtain informal feedback, identify problems, and provide additional guidance. • Monitor the use of a new device after it is implemented to determine the need for additional training, solicit informal feedback on health care worker experience with the device (e. g. , using a suggestion box), and identify possible adverse effects of the device on patient care. 31

Recommendations for DSHS • • • Implement the use of improved engineering controls to reduce needlestick injuries Analyze needlestick and other sharps-related injuries in your workplace to identify hazards and injury trends. Eliminate the use of needle devices where safe and effective alternatives are available. Implement the use of needle devices with safety features and evaluate their use to determine which are most effective and acceptable. Set priorities and prevention strategies by examining local and national information about risk factors for needlestick injuries and successful intervention efforts.

• Ensure that health care workers are properly trained in the safe use and disposal of needles. • Modify work practices that pose a needlestick injury hazard to make them safer. • Promote safety awareness in the work environment. • Establish procedures for and encourage the reporting and timely followup of all needlestick and other sharps-related injuries. Reporting of needlestick injuries is essential to (1) ensure that all health care workers receive appropriate postexposure medical management and (2) provide a record for assessing needlestick hazards in the work environment. • Evaluate the effectiveness of prevention efforts and provide feedback on performance 33

Recommendations for Workers • Avoid the use of needles where safe and effective alternatives are available. • Help your employer select and evaluate devices with safety features. • Use devices with safety features provided by your employer. • Avoid recapping needles. • Plan safe handling and disposal before beginning any procedure using needles.

• Dispose of used needle devices promptly in appropriate sharps disposal containers. • Report all needlestick and other sharps-related injuries promptly to ensure that you receive appropriate followup care. • Tell your employer about hazards from needles that you observe in your work environment. • Participate in bloodborne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination. 35

Advocates at 2006 APIC Meeting Called for Needle Safety Annual meeting participants identified crucial factors that could diminish needlestick injuries: • better safety syringe design (not add-on pieces but instead “user-based design”) • improved training • enhanced reporting processes • data collection 36

RECOMMENDATIONS Use Q. I. Principles in the prevention and management of sharps injuries: 1. Secure administrative support for program 2. Follow recommendations for sharps injury management 3. Study processes, devices, patterns, and root causes related to injuries 4. Develop and use action plans 5. Institute a culture of safety

Monitor Performance Improvement • What data can be used to measure performance improvement for each process? Key points • Develop a checklist of activities • Create and monitor a time line for implementation • Schedule periodic reviews for assessing performance improvements 38