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Moving the needle

By Amanda Silliker
| www.cos-mag.com

Workers at risk of HIV, hepatitis without properly disposing of sharps

In the early 2000s, health-care staff at Toronto East General Hospital (TEGH) were experiencing higher than average injury rates from needles during blood collection, patient injection and IV insertion. To address this, the occupational health and safety director implemented a new program with the goal of reducing needlestick injuries by 20 per cent within one year.

After implementing a slew of changes, the results were outstanding — the hospital saw an 80 per cent reduction in injuries in one year and blood collection injuries were eliminated entirely.

“Prior to it becoming legislation, they already realized this was a hazard, so what can we do about it? They brought in vendors, they educated the staff, they did training, they brought in the safety engineered medical devices to be used, they brought in better sharps containers and that’s what we have been doing for years,” says Sheila Sarman, disability case manager at TEGH.

In 2005 the government of Ontario issued legislation requiring all hospitals to begin using safety engineered needles (SENs) due to the high number of injuries. A 2006 report by the Alliance for Sharps Safety and Needlestick Prevention found health-care workers across Canada incur more than 69,000 sharps injuries per year, 190 per day. Now, almost all other provinces have similar legislation in place; the exceptions being New Brunswick, Quebec and Newfoundland and Labrador.

But  even with legislation, these injuries have not substantially decreased, concluded a study released in March by the Institute for Work and Health in Toronto.

Being ahead of the Ontario legislation was one of the keys to success at TEGH. This early implementation has been identified as a best practice for introducing SENs and reducing sharps injuries in hospitals, found the report.

A safety engineered needle is defined as a hollow-bore needle that has been designed to eliminate or minimize the risk of a skin puncture or needlestick injury to the worker.

There are two main types of SENs are “passive” and “active.” The safety feature in the passive needle is automatic, meaning it requires no additional action on the part of the user. For example, the needle automatically retracts into the barrel of the syringe following the injection. The safety feature in the active needle requires a voluntary action by the user to engage the safety device. For example, a flip down guard is engaged by the user immediately following the injection to cover the used needle prior to disposal.

Needlestick injuries remain the second highest concern for injuries to health-care workers, after back and shoulder injuries, says Betty Metzler, manager of staff health at Sunrise Health Region in Yorkton, Sask.

“We think that one needlestick injury is too many,” she said. “We like that ‘Mission Zero’ as a goal, so we don’t have any needlestick injuries, and that is what our aim is going to be.”

A needlestick injury can run the gamut from a simple first-aid case to lost time or a workers’ compensation case, says Sarman.

If a worker is pricked, the patient could be carrying a blood borne illness and the prick could introduce pathogens for hepatitis B, C or HIV into the health-care worker, says Janice Ward, manager of organizational quality and safety at TEGH. Depending on the injury and the profile of the source patient, a variety of controls are put in place to protect the worker. And the employee’s blood work is monitored six weeks, three months, six months and one year post-incident at TEGH. Aside from the physical health, the mental health of the worker post-incident is also a concern.

There can be health anxiety, post-traumatic stress disorder and depression as a consequence of several months rollout of post-exposure testing and treatment, says Andrea Chambers, author of the IWH study. When she interviewed workers for her study, mental health is what they discussed the most.

“An injury can trickle into their personal life and coming home from their job and telling their spouse and children they have had this exposure can be particularly challenging, and people can have a very different thought process towards their career as a heath-care worker, what their job means, so there is a whole array of complexity after an injury,” she says.

Causes

The IWH study identified three major pathways to needlestick injuries:

Patient action: Injuries sometimes occur during a procedure and as a result of patient action, such as a difficult patient who is aggressive, combative or non-co-operative. These injuries are quite problematic in areas such as emergency and mental health.

Sharps disposal: Injuries can also be linked to improper disposal of SENs, such as not engaging the safety engineered device before putting the needle in the container, or using overfilled sharps disposal bins. This is of particular concern for housekeeping staff because if they are pricked, it is harder to treat them appropriately because the source patient is unknown.

• During activation: The most common injury seen during activation is when a worker is using a SEN that has an active design.

Positive influences

The IWH report outlines many best practices for ensuring the successful implementation of SENs.

External support: Product vendors play an important role in the implementation process. They can offer needs assessments, product suggestions, product evaluation, training and followup consultations.

“These are services that come with no cost implications for the hospital and they result in transferring workload off the organization. Product vendors do have a vested interest in getting their product working and in place, but it seems in this system transition that came out to be quite a huge advantage for hospitals,” says Chambers.

Management support: Support from upper management helps facilitate a smoother transition to SENs. Their support is important in implementing better safety devices, such as passive needles.

Senior leadership at TEGH is a very strong advocate for staff safety which helped with the early implementation of SENs, says Ward.

“The cost of safety engineered needles is undoubtedly more expensive than the old ones, so there is a financial cost and yet it is important to ensure our staff are safe. There really was no pushback; it was the right thing to do,” she says.

Implementation champion: A key support in the transition to SENs is an implementation champion, which could take various forms, such as a health and safety director or a front-line worker.

“This is pretty key… Having somebody on board who is very passionate about needlestick injury prevention, who can see it from the beginning to the end, to really be the supporter of the whole rollout of these devices,” says Chambers. “It helps when it’s someone high up for sure, but front-line workers now have a bit more power, maybe they don’t always recognize that.”
 
Challenges

There are a variety of challenges to implementing safety engineered needles, found the report.

Change fatigue: Some employees reported feeling frustrated with working in an environment that is constantly changing.

The organizations participating in the study that experienced the most change fatigue were the ones that transitioned to SENs in direct response to regulation, which provided a 12-month period for compliance. Hospitals that were not constrained by the compliance date could implement smaller and more proactive changes, which were better received by workers, says the report.

Performance and productivity: In her report, Chambers observed an apparent conflict between the learning curve associated with the new devices and the impact this has on employee performance and patient care. The initial transition had the unintended consequence of temporarily having a negative effect on performance.

“These are devices that some front-line workers have been working with for 20, 25 years… You can take the example of people who draw blood for a living; they would be working with a specific type of needle their entire lives. And for quite a few of the devices, there is a well-known period of adaptation,” says Chambers. “They really do value their performance and productivity.”

Finding time to train: Training is a crucial component to effective SEN rollout, but setting aside time for all employees to complete the training — especially when shifts are distributed 24-7 — is a common problem among hospitals.

“You need to be creative and do the best you can,” says Ward. “We do have someone coming in the earlier hours, so if you have a night shift worker, you have a trainer come in at 6 a.m. and they’re not going off until 7:30 a.m., so you can capture them then. And we have people coming in on the weekends to capture those weekend workers.”

Having the vendor come in and provide hands-on training is an effective approach, says Sarman. The vendor does this at the initial rollout of a new product and is also available for refresher training.

Vendor training is preferred over the train-the-trainer approach, found the IWH report.

“They’re getting the information from the root: This is exactly how you need to use the device. When you have (train-the-trainer) it can be like telephone: When you’re passing along the message, things can get lost and getting it from the source seems to have a lot of advantages,” says Chambers.

Organizational culture

An important influence on the successful rollout of the SEN implementation is an organization’s existing occupational health and safety management systems, says the IWH report. A culture that has existing practices in place for new health and safety equipment, promotes the use of new safety products and practices, and encourages the report of injuries and near misses is important.

“The culture of safety needs to be nurtured more. Staff need to be encouraged to report and do proper followup because they many times think this has gone on for years and nothing bad has ever happened… (or) ‘This is just part of my job,’” says Metzler. “The employee needs to take care of themselves. Their health is first and foremost and then they can take care of the patient.”

Communication

Ongoing communication is important in preventing needlestick injuries. Making use of newsletters, posters and targeted emails that describe recent injuries and explain how to report and prevent them are effective activities, says the IWH report. Many employees involved in the study were unaware needlestick injuries continued to occur.

TEGH always has an occupational health and safety topic of the month, and “needlestick injuries” is a recurring choice. 

“It’s a quick one-pager that’s sent out to the managers and supervisors that they can use in their huddles before shifts, staff meetings or include it on their distribution list to their staff,” says Sarman. “It’s trying to keep certain things out in the forefront and educate the staff on what to do.”

Communication was a key competent to successfully implementing safety engineered needles at TEGH in 2004, and it continues to be an important component of preventing these injuries going forward.

“With an expectation and training and support, we were able to actually get staff through it and I think as long as you keep communicating and listening and being supportive, it can be done,” says Ward. “It’s just having the same message and everybody singing from the same song sheet: ‘It’s a good staff safety initiative.’”

This article originally appeared in the August/September 2014 issue of COS.

 

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