Strategies Top Hospitals Use To Drive Down Needlesticks
‘They are committed — it is not a slogan’
By Gary Evans, Medical Writer
Though seroconversions to HIV or hepatitis infections are rare, needlesticks and other occupational blood exposures can throw healthcare workers into emotional turmoil and considerable angst as they await test results over several months. Thus, some healthcare facilities take a zero-tolerance approach to needlesticks, constantly striving to prevent sharps injuries and exposures.
“In the high achievers — the real sharps-aware hospitals — there is no complacency or toleration of the notion that exposures are simply inevitable,” says Linda Good, RN, PhD, COHN-S, manager of occupational health services at Scripps Health in San Diego. “They have it as a top priority to eliminate them and go to zero, which is a radical idea.”
Indeed, at too many hospitals, sharps injuries and blood exposures are doggedly tracked and reported, but the rates resist reduction and a status quo of low expectations sets in.
“I think organizations get complacent,” Good says. “They track it, and keep their sharps logs, and go to infection control [meetings] and report, ‘For this month we had so many needlesticks and so many splashes.’ It doesn’t alarm them — it’s like it is just a number. Or maybe they feel bad and wish [exposure rates] would come down. But wishing something would happen without any kind of action — it just goes on.”
Good is the lead author of the Exposure Study of Occupational Practice (EXPO-S.T.O.P.), which the Association of Occupational Health Professionals in Healthcare (AOHP) conducts annually.1 In this latest iteration of the survey, researchers interviewed employee health professionals and other leaders at the top facilities to glean some of their strategies for success.
“Even though they are already better than the vast majority of their counterparts, they still have such a commitment to a safe work environment and a culture of safety,” Good says. “They are committed to it — it’s not just a slogan. They really feel that this is important to them. I think any organization puts its emphasis on whatever their top leaders direct them toward and model for them as what is important. That was a characteristic of these hospitals. It was from the very highest [leaders] on down through the ranks. They felt it was everyone’s responsibility to work safely, and that includes [preventing] bloodborne pathogen exposures.”
Inevitable and Unpreventable?
In contrast, some facilities may see needlesticks and blood exposures as inevitable, concluding that they are doing all they can to prevent them.
“It’s not on the radar of some organizations’ top leadership because they think they’ve been dealing with this for so many years,” Good says. “[The perception is] it’s either gotten as good as it’s going to get, or it is impossible to change it, or that nothing really bad has happened. [They say] we haven’t seen a seroconversion — we haven’t seen someone get HIV, hepatitis B, or hepatitis C.”
Of course, if needlesticks and blood exposures were inevitable, there would not be singular hospitals with such low rates of incidents. Facilities with low rates of injuries and exposures certainly reduce the risks of seroconversion, but there is something less tangible at play. These successful facilities also are preventing the anxiety and uncertainty that continue months after a needlestick, as healthcare workers are retested to see if they have acquired a bloodborne pathogen.
“I think they do take that into consideration better than most,” Good says. “They recognize that just because a healthcare worker didn’t get HIV doesn’t mean for the last six months that they and their family haven’t had to worry about this. They may be contemplating whether they made a wise career choice. They may become distracted in their work due to the anxiety of having multiple blood tests. I think [successful facilities] take all that into consideration. Every exposure is potentially devastating. They want to prevent them on behalf of their employees. They want to make sure that it doesn’t happen to any of them.”
The 2015 study was the largest in its five-year history, with 214 facilities participating and 160 reporting data suitable for inclusion in the report. Among the 160 responding hospitals, the top facilities had a sharps injury rate almost 50% lower than the overall average. In subsequent interviews, these “exposure-aware” facilities described multiple program factors that contributed to their success.
Take-home Tips
According to Good and colleagues, these included such strategies as the following:
- Education and training. The top hospitals do not assume new clinical staff are familiar with the sharps prevention policies and the safety-engineered devices (SEDs) used. They require all new clinicians and other new staff handling sharps to:
- Undergo exposure prevention education and training, using scenarios directly related to the new employee’s role.
- Sign off on completion and understanding of the facility’s exposure prevention policy, the work practices relevant to sharps handling and disposal, and show they understand the procedure to report a needlestick or blood exposure.
- New staff must show competency on all SEDs relevant to the staff member’s work area.
- Return for additional training on SEDs is required if a staff member experiences a needlestick. Training also is repeated over time, like every two years, or when new safety devices are adopted.
- Communication. The exposure prevention efforts are data-driven, and reporting and metrics are aligned with the organization’s strategic goals and use a similar terminology and style.
- Exposures are transparently documented and part of the record reported through established committees that reach decision-makers.
- Encourage exposure reporting by staff — including “near misses” — by establishing a convenient and efficient process.
- Conduct “awareness campaigns” to remind front-line staff to remain vigilant for exposure risks as they go about their duties.
- Use signs or flagging on a patient room to alert co-workers that a sharps procedure is in progress, thereby avoiding a sudden entry and startling the patient or healthcare worker during the procedure.
- Investigation. A common mantra is “no blame, no shame” as part of exposure reporting policies that are nonpunitive. This approach encourages staff reporting of exposures and doesn’t drive the problem underground.
- Conduct a systematic root cause analysis of needlesticks and blood exposures, avoiding assumptions on both what happened and how to solve it. Allow the investigation to methodically reveal the facts in the incident.
- Involve direct-care staff when an unusual trend or process is identified. These workers often will have insight and solutions from their front-line vantage point of the work flow.
- If exposures or injuries involve an SED, ensure users are correctly activating the safety mechanism.
- Involve the unit manager, the injured employee, and senior leadership when indicated, in every follow-up investigation.
- Engagement. Hold safety forums and open-ended discussions with staff that may begin with a thought-provoking question, such as, “If you arrived to work today and it was a safer environment, what would it look like?”
- Reach out to front-line staff as “safety advocate” partners that can help employee health in injury-reduction initiatives.
- Hold both the front-line caregiver and management responsible for their parts in the “safety formula.” Senior leadership should recognize and praise successes.
Success Breeds Success
For example, the AOHP researchers interviewed an occupational health nurse who used successful safety initiatives to gain “momentum” toward future projects. A successful project in safe patient handling was used to justify support for a proposal to reduce bloodborne pathogen exposures.
“Everyone wants to be associated with a winner and they want to have things shown in the best light,” Good says. “I think it is important to use the process improvement framework that your organization uses. So, for instance, if it’s it Six Sigma or whatever the [quality improvement] mechanism is, use that. Don’t [assume management] knows you are doing good things, and don’t just do something ‘one off’ [and stop]. If your hospital gives a quality award every year that uses a certain format, then highlight what you’re doing in those same terms. That way, it stands side-by-side with the other successful projects that are being recognized by the organization.”
While such successes can be celebrated, some sharps injury settings pose persistent and long-standing problems where change may be slow in coming. A frequently cited example is the operating room, where surgeons working with traditional tools may be difficult to convert to blunt suture needles and other devices designed to prevent injuries.
“We are definitely seeing some very encouraging progress in the the use of the ‘neutral zone’ and getting away from the direct passing [of sharps],” Good says. “Those [protocols] are taking hold and resulting in safer situations. They have either a basin of some sort, or a designated area so that the technician or nurse can place the sharp into the neutral zone and remove their hands before the surgeon picks it up. There isn’t any direct passing.”
ORs at the top hospitals in the study cited partnerships between surgeons and anesthesiologists as the top imperative to ensure successful adoption of safety measures. Still, in the tight quarters and tense atmosphere of an OR procedure, convincing someone to try out new safety equipment may face considerable resistance.
For example, one anesthesiologist observed a demonstration of a proposed safety-engineered IV start needle, but conceded he likely would resort to the less safe, but more familiar, method in a high-pressure situation, Good noted.
As sharps safety devices are phased in for various procedures, some change may be generational as those trained initially on such devices use them from the beginning of their careers.
“I think as the next generation comes up, they will have learned the safety devices so there won’t be that learning curve,” Good says. “When I was starting out in nursing a long time ago, we didn’t wear gloves for hardly anything. When people started suggesting that we should take standard precautions, we thought we can’t possibly work with gloves on. Well, now we wouldn’t think of doing anything without gloves. It’s just a change in your practice, but that learning curve piece is awkward and you want to avoid it if you can. Some have to be forced to adopt [changes]. But generationally, I think we are going to continue to see these changes made.”
Editor’s note: More information on the EXPO-S.T.O.P study and many other employee health topics and issues will be discussed at the AOHP annual conference Sept. 6-9, 2017, in Denver.
REFERENCE
- Good L, Grimmond T. Proven Strategies to Prevent Bloodborne Pathogen Exposures in EXPO-S.T.O.P. Hospitals. AOHP Jrl Winter 2017.
Though seroconversions to HIV or hepatitis infections are rare, needlesticks and other occupational blood exposures can throw healthcare workers into emotional turmoil and considerable angst as they await test results over several months.
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