overview sharps and ergonomic safety in the healthcare setting
TRANSCRIPT
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OVERVIEWAnsell Healthcare Products LLC has an ongoing commitment to the development of quality products and services for the healthcare industry. This self-study, Clinical Reference Manual: SHARPS AND ERGONOMIC SAFETY ISSUES IN THE HEALTHCARE SETTING, is one in a series of continuing education services provided by Ansell. This education module examines sharps injuries and ergonomic issues.Accidental sharps injuries and ergonomic issues in the perioperative setting are serious problems. Many healthcare workers acquire infectious diseases from bloodborne pathogens or injuries in the course of their work. Lifting and moving patients causes at least 12% of nurses to leave the profession each year. The cost of injury and exposure takes an emotional and financial toll on healthcare workers, their families and the facilities where they work. Awareness of the risk associated with these exposures has led to an emphasis on protection for healthcare workers and patients alike. The Center for Disease Control (CDC), Occupational Safety and Health Administration (OSHA) and many other professional organizations have formulated guidelines and regulations as a means of protection and safety. This education module examines basic strategies and processes that can raise awareness of and help minimize the risk of sharps and ergonomic injuries.
PROGRAM OBJECTIVESUpon completion of this educational activity, the learner should be able to:
1. Review the OSHA Bloodborne Pathogen Standard
2. Discuss the current state of Healthcare Worker compliance
3. Discuss facts, statistics and regulations pertaining to sharps and ergonomic safety
4. Explain the professional standards associated with sharps and ergonomic safety issues
5. Describe solutions to sharps and ergonomic safety issues
INTENDED AUDIENCEThe information contained in this self-study guidebook is intended for use by healthcare professionals who are responsible for or involved in the following activities related to this topic:
•Educating healthcare workers
•Establishing institutional or departmental policies and procedures
•Decision-making responsibilities for sharps safety and ergonomic products
•Maintaining regulatory compliance with agencies such as OSHA, ANA and CDC
•Managing employee health and infection prevention services
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GINSTRUCTIONSAnsell Healthcare is a provider approved by the California Board of Registered Nursing, Provider # CEP 15538 for 2.5 contact hour(s). Obtaining full credit for this offering depends on completion of the self-study materials on-line as directed below. Approval refers to recognition of educational activities only and does not imply endorsement of any product or company displayed in any form during the educational activity.To receive contact hours for this program, please go to the "Program Tests" area and complete the post-test. You will receive your certificate via email.
AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETIONAny learner who does not successfully complete the post-test will be notified and given an opportunity to resubmit for certification.For more information about our educational programs or hand-barrier-related topics, please contact Ansell Healthcare Educational Services at 1-732-345-2162 or e-mail us at [email protected]
Planning Committee Members: Lori Jensen, RN (employed at Ansell Healthcare at the time of planning of this module) Patty Taylor RN, BA Pamela Werner, MBA, BSN, RN CNOR
As employees of Ansell Mrs. Jensen, Mrs. Taylor and Ms. Werner have declared an affiliation that could be perceived as posing a potential conflict of interest with development of this self-study module.
Roy Zacharias Jr., CST, BS, FAST
As an employee of The Meridian Institute, Mr. Zacharias has declared an affiliation that could be perceived as posing a potential conflict of interest with the development of this self-study module.
This module will include discussion of commercial products refrenced in generic terms only.
The information presented herein is intended to provide a general overview of application and regulations but should not be considered legal advice.
Ansell Healthcare Products LLC
111 Wood Avenue South, Suite 210 Iselin, NJ 08830 USATel: 1-800-952-9916 www.ansellhealthcare.com
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CONTENTS Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Sharps Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OSHA Rights and Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OSHA Bloodborne Pathogens Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Sharps Crisis Identified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Crisis Continues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How Common are Sharps Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Cost Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Review: Origins of Healthcare Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
OSHA Fact sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Other Influenzing Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Professional Organizational Influence-Sharps Safety . . . . . . . . . . . . . . . . . . . . 11
Resitance to Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Facts and Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Compliance and OSHA Inspection Information . . . . . . . . . . . . . . . . . . . . . . . . . 18
Benefits to complying with Sharps Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Ergonomic Workplace Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Human Factors Increasing the Risk of Ergonomic Mishaps Contents . . . . . . . . 22
Unsafe Work Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Regulatory Organizations Influence- Ergonomics . . . . . . . . . . . . . . . . . . . . . . . 23
Professional Organizational Influence- Ergonomics . . . . . . . . . . . . . . . . . . . . . 25
Benefits of Complying with Ergonomic Safety . . . . . . . . . . . . . . . . . . . . . . . . . 28
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
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TEST YOUR KNOWLEDGE
The following brief quiz will help to
develop a starting point for this topic:
1. Every member of the surgical team
has a critical role facilitating
exposure prevention.
❏ True ❏ False
2. Every employer who has employees
with occupational exposure to blood
is required to have a written exposure
control plan.
❏ True ❏ False
3. The pathogens standard does not
require employers to adopt the use
of universal precautions, engineering
controls, work practice controls and
PPE.
❏ True ❏ False
4. Wyoming was the first state in the
U.S. to pass no lift law legislation
in 2006, to implement safe patient
handling and movement.
❏ True ❏ False
5. Nursing personnel have the highest
back injury claim rates of any
occupation or industry.
❏ True ❏ False
DEFINITIONSOSHA Definitions
Engineering Controls means controls that isolate or remove the bloodborne pathogens hazard from the workplace, e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems.
Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed, e.g., prohibiting recapping of needles by a two-handed technique.
Needleless systems means a device that does not use needles for: (1) The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; (2) The administration of medication or fluids; or (3) Any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.
Sharps with engineered sharps injury protections means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.
Answers: 1. T 2. T 3. F (it does require) 4. F (Texas) 5. T
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INTRODUCTIONThere are more than 50 million surgeries (30 million in acute care hospitals and 20 in non-hospital settings) performed in US hospitals each year. In the not-so-distant past, healthcare workers (HCWs) may have considered percutaneous injuries part of the job. That is not the case any longer. With the infection prevention practice regulations recommended by the CDC for Universal Precautions, and OSHA enforcing the use of Universal Precautions and the enactment of the Bloodborne Pathogens (BBP) Standard (1991), there is a strong regulatory influence for employers and employees to be compliant.
Additionally, on Nov. 6, 2000, the Needlestick and Safety Prevention Act was enacted by the 106th Congress. This revised the bloodborne pathogens standard, in effect under the Occupational Safety and Health Act of 1970 (OSHA) to include safer medical devices, such as sharps with engineered sharps injury protections and needleless systems, as examples of engineering controls designed to eliminate or minimize occupational exposure to bloodborne pathogens through needlestick and other percutaneous injuries.1 Accidental sharps injuries in the perioperative setting continue to be a serious and persistent problem. Many healthcare workers acquire infectious diseases from bloodborne pathogens or injuries in the course of their work. Sharps injuries are an occupational risk for health care professionals around the world. According to Jagger et al, “An estimated 384,000 percutaneous injuries are reported by health care workers in hospitals in the United States each year, placing them at risk of exposure to human
immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV)”.2
Another ongoing issue in healthcare is the movement and handling of patients and equipment. Lifting and moving patients leads to at least 12% of nurses leaving the profession annually.3 Yassi et al (1995) found that lifting and transferring patients were two of the most common mechanisms for back injuries among nurses.4
SHARPS SAFETYOSHA President Nixon signs the Occupational Safety and Health (OSH) Act (OSHA) into law
The Occupational Safety and Health Administration (OSHA) is a federal agency and is a part of the US Dept. of Labor. It was created 42 years ago with the Occupational Safety and Health Act of 1970. Congress created OSHA to ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.
Under the Act, the Occupational Safety and Health Administration (OSHA) was created within the Department of Labor to:
•Encourage employers and employees to reduce workplace hazards and to implement new or improve existing safety and health programs;
•Provide for research in occupational safety and health to develop innovative ways of dealing with occupational safety and health problems;
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•Establish "separate but dependent responsibilities and rights" for employers and employees for the achievement of better safety and health conditions;
•Maintain a reporting and recordkeeping system to monitor job-related injuries and illnesses;
•Establish training programs to increase the number and competence of occupational safety and health personnel;
•Develop mandatory job safety and health standards and enforce them effectively; and
•Provide for the development, analysis, evaluation and approval of state occupational safety and health programs.5
OSHA standards are rules that illustrate the measures employers are legally obligated to pursue in order to protect healthcare workers from hazards. These standards require the use of certain safe practices and equipment, and require employers to monitor certain workplace hazards.
The OSH act covers employers and their employees either directly through federal OSHA or through an OSHA-approved state program. State programs must meet or exceed federal OSHA standards for workplace safety and health.
There are currently 22 states and jurisdictions operating complete state plans (covering both the private sector and state and local government employees) and 5 - Connecticut, Illinois, New Jersey, New York and the Virgin Islands - which cover public employees only. (Eight other states were approved at one time but subsequently withdrew their programs)
Federal OSHA authority extends to all private sector employers with one or more employees, as well as federal civilian employees in the remaining states.
In the remaining jurisdictions where Federal OSHA has authority, hospitals operated by state, territorial or local governments are required to comply with the Bloodborne Pathogens standard with enforcement by the Centers for Medicare and Medicaid Services (CMS) (42 U.S.C. 1395cc(a)(1)(V) and (b)(4)
OSHA RIGHTS AND DUTIESIt is important to note that there are OSH Act employer and employee Rights and Duties
Employer responsibilities include but are not limited to;
1. The employer shall furnish a place of employment free from recognized hazards that are causing or likely to cause death or serious physical harm to employees.
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2. Shall comply with OSHA standards
3. Shall not restrict an inspection
4. May participate in standards development
5. Are entitled to review citations issued
6. May seek a variance to a standard
7. Are entitled to protection of trade secrets
Employee responsibilities include but are not limited to;
1. Must comply with OSHA standards/regulations
2. Can request an inspection
3. Be afforded appropriate protective measures (labels, control techniques, personal protective equipment, monitoring) to control exposures to biological or physical agents
4. Shall not be discharged or discriminated against for filing complaints with OSHA
5. Can object to abatement time given to correct violations in a citation
6. Has the right to refuse medical treatment on religious grounds
It is important to note that compliance with OSHA standards/regulations is the law. Shall means that the referenced procedure is a requirement.
For example within the standards you may read;
1910.1030 (d)(2)(ii) states, “Engineering and work practice controls shall be used to eliminate or minimize employee exposure.”
"Where engineering controls will reduce employee exposure either by removing, eliminating, or isolating the hazard, they must be used.” CPL 02-02-069
“Employers must select and implement appropriate engineering controls to reduce or eliminate employee exposure.”
OSHA BLOODBORNE PATHOGENS STANDARDThe purpose of OSHA’s Bloodborne Pathogens Standard, which applies to workers who are exposed to blood and body fluids, helps produce a safe environment for healthcare workers and patients. The best way to accomplish this goal is to create a safe environment for healthcare workers and patients by controlling exposure to blood or other potentially infectious materials.
In 1991, OSHA issued the standard regulating occupational exposure to bloodborne pathogens. This is federal law and spells out specific guidelines that employers and employees must follow. Due to this regulation, healthcare workers saw a significant decrease in bloodborne disease as a result of compliance.
Studies demonstrated that adopting safer medical devices, such as engineered sharp injury prevention products and needleless systems, can be extremely effective in reducing accidental sharps injuries. Therefore, in 2001, OSHA implemented The Needlestick Safety and Prevention Act.
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SHARPS CRISIS IDENTIFIED The Needlestick Safety and Prevention Act (the Act) (Pub. L. 106-430) was signed into law on November 6, 2000 because occupational exposure to bloodborne pathogens from accidental sharps injuries in healthcare and other occupational settings continued to be a serious problem.
The Act mandated the revision of the 1991 OSHA BBP Standard to require the use of engineered sharps injury prevention devices. OSHA requires that employers who have employees with occupational exposure to bloodborne pathogens must, where appropriate, use effective engineering controls, including safer medical devices, in order to reduce the risk of injury from needlesticks and from other sharp medical instruments.6
Listed below is a more detailed summary of the changes mandated by The Needlestick Safety and Prevention Act:
Exposure Control Plan The revision includes new requirements regarding the employer's Exposure Control Plan, including an annual review and update to reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens.
The employer must: Take into account innovations in medical procedure and technological developments that reduce the risk of exposure (e.g., newly available medical devices designed to reduce needlesticks); and document consideration and use of appropriate, commercially-available, and effective safer devices (e.g., describe the devices identified as candidates for use, the method(s) used to evaluate those devices, and justification for the eventual selection).
Employee Input Employers must solicit input from non-managerial employees responsible for direct patient care regarding the identification, evaluation, and selection of effective engineering controls, including safer medical devices. Employees selected should represent the range of exposure situations encountered in the workplace.
Documentation of employee input Employers are required to document, in the Exposure Control Plan, how they received input from employees.
Recordkeeping Employers who are required to maintain a log of occupational injuries and illnesses under existing recordkeeping rules, must also maintain a sharps injury log. That log will be maintained in a manner that protects the privacy of employees. At a minimum, the log will contain the following: the type and brand of device involved in the incident; location of the incident (e.g., department or work area); and description of the incident.
Modification of Definitions The revision to the bloodborne pathogens standard includes modification of definitions relating to engineering controls. Two terms have been added to the standard, while the description of an existing term has been amended.
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Engineering Controls Engineering Controls include all control measures that isolate or remove a hazard from the workplace, such as sharps disposal containers and self-sheathing needles. The original bloodborne pathogens standard was not specific regarding the applicability of various engineering controls (other than the above examples) in the healthcare setting. The revision now specifies that "safer medical devices, such as sharps with engineered sharps injury protections and needleless systems" constitute an effective engineering control, and must be used where feasible.
Sharps with Engineered Sharps Injury Protections This is a new term which includes non-needle sharps or needle devices containing built-in safety features that are used for collecting fluids or administering medications or other fluids, or other procedures involving the risk of sharps injury.
Needleless Systems This is a new term defined as devices which provide an alternative to needles for various procedures to reduce the risk of injury involving contaminated sharps.
Needleless systems means a device that does not use needles for:
(1) The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; (2) The administration of medication or fluids; or (3) Any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.
THE CRISIS CONTINUESAccidental exposure to blood and body fluids due to sharps injuries continues to be a serious problem in healthcare, especially in the surgical setting. After the Needlestick Safety legislation was implemented, it was noted that sharps injury rates in nonsurgical settings dropped 31.6%, but increased 6.5% in surgical settings.7 An estimated 384,000 percutaneous injuries (i.e. sharps injuries) are reported by healthcare workers in the U.S. each year.8
Estimates for all health care settings are that 600,000 to 800,000 needlestick and other percutaneous injuries occur among health care workers annually. Such injuries can involve needles or other sharps contaminated with bloodborne pathogens, such as HIV, HBV, or HCV.9 Approximately 23% of those injuries occur in the surgical setting.10 Nearly half (48%) of these injuries occur during the use of the item, 30 % occur after the use of the item, 11% occur during the disposal of the item, 3% occur during recapping used needles, and 8% occur in other ways.11 The top three sharps injuries that occur are from suture needles (43.4%), scalpel blades (17%) and syringes with needles (12%).
A recent survey among surgical residents found that 51% of their needlesticks were unreported.12
Unfortunately, in the healthcare setting all employees are at risk of being exposed to bloodborne pathogens while at work. Surgeons and surgical residents are most often the original users of devices causing these injuries. Nurses and surgical technicians were most often injured by devices originally used by others.13
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Therefore, nurses and surgical technicians need to be aware of and follow safe practice guidelines in order to ensure they are protected.
HOW COMMON ARE SHARPS INJURIES?Sharps injuries remain a far too common hazard. On average, 30% of nursing and laboratory employees suffer sharps injuries sometime during their career. Many of the statistics underestimate the true seriousness of the situation because many workers don’t report their injuries. Even though the employer may encourage workers to report sharps injuries, there is an emphasis to keep sharps injury numbers low, so they often go unreported.14
THE COST IMPACTThe cost of ONE non-infecting sharps exposure will run between $500 (low risk exposure) and $3,000 (high risk exposure) simply due to reporting, medical testing, precautionary treatments and lost work hours. Social and psychological costs are immeasurable.15 If an infection occurs, the cost could be well over $300,000 per incident.16
The cost of one sharps injury alone can be persuasive enough to use safer sharps practices. One sharps injury can affect various costs for the health care facility, including but not limited to:
•Loss of employee time
•Cost of tying up staff to investigate the injury
•Expense of laboratory testing
•Cost of treatment for infected staff
•Cost of replacing staff17
In addition to costs incurred by the health care facility, the stress on the affected worker and the worker’s family can be enormous. In addition to the initial concern, testing for bloodborne pathogens can last for months, producing feelings of anxiety and distress for an extended period of time.
REVIEW: ORIGINS OF HEALTHCARE STANDARDS
1983: OSHA Hepatitis B guidelines; CDC warns about recapping
1991: Federal OSHA issued Bloodborne Pathogens Standard
•Little data on efficacy of safety devices; limited choice of safety devices
•Emphasis on evaluation not implementation
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• Implement the use of universal precautions(treating all human blood and OPIM as if knownto be infectious for bloodborne pathogens).
• Identify and use engineering controls. Theseare devices that isolate or remove the blood-borne pathogens hazard from the workplace.They include sharps disposal containers, self-sheathing needles, and safer medical devices,such as sharps with engineered sharps-injuryprotection and needleless systems.
• Identify and ensure the use of work practicecontrols. These are practices that reduce thepossibility of exposure by changing the way atask is performed, such as appropriate practicesfor handling and disposing of contaminatedsharps, handling specimens, handling laundry,and cleaning contaminated surfaces and items.
• Provide personal protective equipment (PPE),such as gloves, gowns, eye protection, andmasks. Employers must clean, repair, andreplace this equipment as needed. Provision,maintenance, repair and replacement are at nocost to the worker.
• Make available hepatitis B vaccinations to allworkers with occupational exposure. This vac-cination must be offered after the worker hasreceived the required bloodborne pathogenstraining and within 10 days of initial assignmentto a job with occupational exposure.
• Make available post-exposure evaluation andfollow-up to any occupationally exposed work-er who experiences an exposure incident. Anexposure incident is a specific eye, mouth,other mucous membrane, non-intact skin, orparenteral contact with blood or OPIM. Thisevaluation and follow-up must be at no cost tothe worker and includes documenting theroute(s) of exposure and the circumstances
Protections Provided by OSHA’sBloodborne Pathogens StandardAll of the requirements of OSHA’s BloodbornePathogens standard can be found in Title 29 of theCode of Federal Regulations at 29 CFR 1910.1030.The standard’s requirements state what employ-ers must do to protect workers who are occupa-tionally exposed to blood or other potentiallyinfectious materials (OPIM), as defined in the stan-dard. That is, the standard protects workers whocan reasonably be anticipated to come into con-tact with blood or OPIM as a result of doing theirjob duties.
In general, the standard requires employers to:
• Establish an exposure control plan. This is awritten plan to eliminate or minimize occupa-tional exposures. The employer must preparean exposure determination that contains a listof job classifications in which all workers haveoccupational exposure and a list of job classifi-cations in which some workers have occupa-tional exposure, along with a list of the tasksand procedures performed by those workersthat result in their exposure.
• Employers must update the plan annually toreflect changes in tasks, procedures, and posi-tions that affect occupational exposure, andalso technological changes that eliminate orreduce occupational exposure. In addition,employers must annually document in the planthat they have considered and begun usingappropriate, commercially-available effectivesafer medical devices designed to eliminate orminimize occupational exposure. Employersmust also document that they have solicitedinput from frontline workers in identifying, eval-uating, and selecting effective engineering andwork practice controls.
FactSheetOSHA’s Bloodborne Pathogens StandardBloodborne pathogens are infectious microorganisms present in blood that cancause disease in humans. These pathogens include, but are not limited to, hepatitis Bvirus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), thevirus that causes AIDS. Workers exposed to bloodborne pathogens are at risk forserious or life-threatening illnesses.
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This is one in a series of informational fact sheets highlighting OSHA programs, policies or standards. It does not impose any new compliance requirements. For a comprehensive list of compliance requirements of OSHA standards or regulations, refer to Title 29 of the Code of FederalRegulations. This information will be made available to sensory-impaired individuals upon request.The voice phone is (202) 693-1999; the teletypewriter (TTY) number is (877) 889-5627.
under which the exposure incident occurred;identifying and testing the source individual forHBV and HIV infectivity, if the source individualconsents or the law does not require consent;collecting and testing the exposed worker’sblood, if the worker consents; offering post-exposure prophylaxis; offering counseling; andevaluating reported illnesses. The healthcareprofessional will provide a limited written opin-ion to the employer and all diagnoses mustremain confidential.
• Use labels and signs to communicate hazards.Warning labels must be affixed to containers of regulated waste; containers of contaminatedreusable sharps; refrigerators and freezers containing blood or OPIM; other containersused to store, transport, or ship blood or OPIM;contaminated equipment that is being shippedor serviced; and bags or containers of con-taminated laundry, except as provided in thestandard. Facilities may use red bags or redcontainers instead of labels. In HIV and HBVresearch laboratories and production facilities,signs must be posted at all access doors whenOPIM or infected animals are present in thework area or containment module.
• Provide information and training to workers.Employers must ensure that their workersreceive regular training that covers all elementsof the standard including, but not limited to:information on bloodborne pathogens and dis-eases, methods used to control occupational
exposure, hepatitis B vaccine, and medical eval-uation and post-exposure follow-up procedures.Employers must offer this training on initialassignment, at least annually thereafter, andwhen new or modified tasks or proceduresaffect a worker’s occupational exposure. Also,HIV and HBV laboratory and production facilityworkers must receive specialized initial training,in addition to the training provided to all work-ers with occupational exposure. Workers musthave the opportunity to ask the trainer ques-tions. Also, training must be presented at aneducational level and in a language that work-ers understand.
• Maintain worker medical and training records.The employer also must maintain a sharpsinjury log, unless it is exempt under Part 1904 --Recording and Reporting Occupational Injuriesand Illnesses, in Title 29 of the Code of FederalRegulations.
Additional InformationFor more information, go to OSHA’s BloodbornePathogens and Needlestick Prevention Safety andHealth Topics web page at: https://www.osha.gov/SLTC/bloodbornepathogens/index.html.
To file a complaint by phone, report an emergency,or get OSHA advice, assistance, or products, con-tact your nearest OSHA office under the “U.S.Department of Labor” listing in your phone book, orcall us toll-free at (800) 321-OSHA (6742).
Occupational Safetyand Health Administrationwww.osha.gov 1-800-321-6742
For assistance, contact us. We can help. It’s confidential.
DSG 1/2011
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2000: Needlestick Safety and Prevention Act required revision of 1991 Federal BBP Standard
•Acknowledgement of persistent problem
•Substantial increase in the number and assortment of effective safety devices
•Published studies demonstrating efficacy
Needlestick Safety And Prevention Act Directed OSHA to revise 1991 Bloodborne Pathogens Standard.
OTHER INFLUENCING ORGANIZATIONSNATIONAL INSTITUTION FOR OCCUPATIONAL SAFETY AND HEALTH (NIOSH)
The National Institute for Occupational Safety and Health (NIOSH) develops and establishes occupational health and safety standards. The Occupational Safety and Health Act of 1970 created NIOSH. NIOSH conducts research to develop new criteria for improving health and safety standards and makes recommendations on those standards. It is part of the Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services.
OSHA and NIOSH were both established by the Occupational Safety and Health Act of 1970.
The difference between OSHA and NIOSH is that OSHA issues the regulations and conducts inspections to enforce them, whereas NIOSH researches safety and health and recommends safety and health standards.
NIOSH has created publications pertaining to needlestick safety such as the “Preventing Needlestick Injuries in Health Care Settings” ALERT and the “Stop Sticks” Campaign.
The NIOSH alert is for education purposes and provides existing scientific information pertaining to the risk that healthcare workers can encounter via a needlestick injury and the transmission of bloodborne pathogens. The document focuses on needlestick injuries in order to provide necessary information to prevent all sharps related injuries and associated bloodborne infections. The “Stop Sticks” campaign was developed to be highly customizable so that a facility can decide which components best fit their needs. A complete campaign can be conducted or only specific components may be used, depending on the requirements and resources available at a facility. The “Stop Sticks” campaign may be presented as a stand-alone initiative, or it may be tied with other initiatives, such as introduction of a new safety device or an annual refresher to remind staff of the hazards associated with sharps injuries.
To see complete information on stop sticks please go to the CDC website: http://www.cdc.gov/niosh/stopsticks/
To see the full document on “Preventing Needlestick Injuries in Health Care Settings” please go to http://www.cdc.gov/niosh/docs/2000-108/pdfs/2000-108.pdf
THE JOINT COMMISSION
The purpose and mission of the Joint Commission is “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”18
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The Joint Commission published an issue of Sentinel Event Alert devoted to increasing organizational understanding of needlestick and sharps injuries and offering information on preventing the occurrence of needlestick injuries, as well as advising organizations of the new requirements adopted in the Needlestick Safety and Prevention Act, passed unanimously by Congress and signed into law on November 6, 2000.19
The Joint commission focuses on all aspects of patient safety, for institution accreditation and certification and added safety measures, in the National Patient Safety Goals. To be accredited, it is mandatory to comply with these goals and patient safety measures.
PROFESSIONAL ORGANIZATIONAL INFLUENCE- SHARPS SAFETY Professional organizations have a great influence on what surgeons, nurses and surgical technologists strive to achieve in their work practice. Each of the following organizations was created to improve the quality of care. They each have specific standards and recommended practices associated with sharps injury prevention.
•Association of periOperative Registered Nurses (AORN)
•American College of Surgeons (ACS)
•American Nurses Association (ANA)
•Association of Surgical Technologists (AST)
ASSOCIATION OF PERIOPERATIVE REGISTERED NURSES (AORN)
AORN strives to promote safety and favorable outcomes for patients undergoing operative and other invasive procedures by providing practice support and professional development opportunities to perioperative nurses. The information in the recommended practices is a collaboration between professional and regulatory organizations, industry leaders, and other health care partners who support the same mission.20
AORN developed a guidance document about these serious issues to suggest strategies to overcome obstacles to compliance with established sharps safety protocols.21
AORN POSITION STATEMENT “The perioperative environment poses unique challenges for reducing the risk of injuries from sharp devices. Surgery involves precise, regimented actions that require planning, communication, and team work. These same elements can be employed to mitigate the inherent hazards associated with sharp devices encountered in the perioperative setting. Perioperative RNs should actively participate in the development and implementation of strategies to reduce the risk of sharps injuries to health care team members.”22
The following is included in the AORN position statement:
•Adopt and incorporate safe habits into daily work activities when preparing and using sharp devices.
•Focus attention on the intent of the action when working with sharp items, and minimize rushing and distractions while applying safety techniques during critical moments. 11
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•During preparation for operative or other invasive procedures:
– Inspect the surgical field for adequate lighting and space to perform the procedure.
– Organize the work area so that the sharps are always pointed away from staff members.
– Establish a separate area to place reusable sharps for safe handling during the procedure.
– Use standardized sterile field set-ups; and include identification of the neutral zone in the preoperative briefing.
•During the procedure:
– Wear two pairs of gloves and monitor gloves for punctures.
– Encourage the use of blunt suture needles.
– Use neutral zones or hands-free techniques for passing sharp items whenever possible or practical, instead of passing hand-to-hand.
– Give verbal notification when passing a sharp device.
– Keep visual contact with the procedure site and the sharp device.
– Take steps to control the location of the sharp device.
– Be aware of other staff members in the area when handling a sharp device.
– Keep track of and account for all sharp items throughout the procedure.
– Contain used sharps on the sterile field in a designated, disposable, puncture-resistant needle container, and replace it as necessary.
– Check to be sure the disposable, puncture resistant needle container is securely closed before handing it off the field.
– Load suture needles using the suture packet to assist in mounting the suture needle in the needle holder, and use the appropriate instrument to adjust and unload the needle.
– Remove the needle from the suture before tying, or use “control-release” sutures.
– activate the safety feature of a safety engineered device immediately after use according to manufacturers’ instructions.
– Keep hands away from the surgical site when sharp items are in use (eg, suturing, cutting).
– Use one-handed or blunt instrument-assisted suturing techniques to avoid finger contact with the suture needle or tissue being sutured.
– Provide a barrier between the hands and the needle after use; and use gloves and an instrument to pick up sharp items (eg, suture needles, hypodermic needles, scalpel blades) that have fallen on the floor.
•During post procedure clean up:
– Inspect the surgical setup used during the procedure for sharps.
– Transport reusable sharps in a closed, secure container to the designated clean-up area.
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– Inspect the sharps container for overfilling before discarding disposable sharps in it.
– Make sure the sharps container is large enough to accommodate the entire device.
– Avoid bringing hands close to the opening of a sharps container.
– Do not place hands or fingers into a container to dispose of a device.
– Keep hands behind the sharp tip when disposing.23
(For the complete AORN Sharps Injury Prevention See 2012 Perioperative Standards and Recommended Practices pg 711-715)
AMERICAN COLLEGE OF SURGEONS (ACS)
Sharps Safety Recommendations: The ACS Board of Regents approved the recommended standards of practice pertaining to sharps injury prevention at its June 2007 meeting. The American College of Surgeons is in support of programs that implement practices that strive to remove, safeguard, or standardize the use of sharp instruments in the operating room setting.24
The ACS also recommends the use of “Structured evaluations and user- based criteria that include performance standards, task analysis, simulation, and training programs for devices intended to reduce sharps injuries in the OR.”25
The ACS is agreement that it is critical to follow a team approach to sharps safety. ACS also states that “Hospitals and health care facilities should make sharps injury reduction techniques and instruments available for surgeons and OR personnel.”26
The ACS recommends:
•The universal adoption of the double glove (or underglove) technique in order to reduce body fluid exposure due to glove tears and sharps injuries in surgeons and scrub personnel.”27
•The universal adoption of blunt tip suture needles for the closure of fascia and muscle in order to reduce needlestick injuries to surgeons and OR personnel.”28
•The use of a hands-free technique and a designated neutral zone. For example a towel, mayo stand, magnetic pad, etc.29
•The use of Engineered Sharps Injury Prevention (ESIP) devices as an adjunctive safety measure to reduce sharps injuries during surgery except in situations where it may compromise the safe conduct of the operation or safety of the patient.30
AMERICAN NURSES ASSOCIATION (ANA)
The American Nurses Association issued a statement, “Moving the Sharps Safety Agenda Forward in the United States” which calls upon health care employers and workers, professional organizations, federal agencies, manufacturers and educational institutions to work together to ensure that the safest devices are available, safety policies are implemented, personnel is educated, and laws and regulations are enforced. Those reco- mmendations are summarized below.31
For more background and a full description of the recommendations, please refer to the actual statement at http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/SafeNeedles/SharpsSafety/ConsensusStatement-SharpsSafety.pdf
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1. Improving Sharps Safety in Surgical Settings
•Adopt site-specific sharps safety policy for the operating room.
•Health care workers in surgical settings collaborate to develop and implement sharps safety standards and practices.
•Professional groups and manufacturers encourage the use of blunt suture needles where appropriate.
• Increase Bloodborne Pathogens Standard compliance in surgical settings.
2. Understanding and Reducing Exposure Risks in Non- Hospital Settings
•Support epidemiological research that evaluates risks to workers.
• Increase OSHA focus on enforcement of the Bloodborne Pathogens Standard in non-hospital settings.
•Ensure sharps safety is a priority and appropriate devices and educational and training materials are available.
3. Involving Frontline Health Care Workers in the Selection of Safety Devices
•Professional organizations educate their members about the Needlestick Act's provisions.
•Employers consistently involve frontline workers in the selection of devices, as required by regulation.
•Conduct research to assess whether and to what extent health care workers are being included in the device selection process.
4. Addressing Gaps in Safety Devices: The Need for Continued Innovation
•Assess and prioritize device needs for specific clinical applications, monitor progress in closing existing gaps, and identify future needs.
•Develop suture and scalpel safety designs that both reduce risk and are comfortable and intuitive for surgeons' use.
5. Enhancing Education and Training
•Develop standardized curricula on bloodborne pathogen exposure prevention and the selection and use of safety-engineered devices.
•Employers provide annual instruction to all workers at risk of sharps injuries on the appropriate use and disposal of safety devices.
•Develop training strategies for the introduction of new devices, so frontline workers understand proper use and disposal.32
ASSOCIATION OF SURGICAL TECHNOLOGISTS (AST)
Recommended Standards of Practice for Sharps Safety and Use of the Neutral Zone
AST created Recommended Standards of Practice to offer support to health care facilities in support of sharps safety and use of the neutral zone in the perioperative setting. The AST Education and Professional Standards Committee wrote, "Recommended Standards of Practice for Sharps Safety and Use of the Nuetral Zone" and made it effective October 27, 2006.33
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The AST Recommended Standards are based upon the protocols set up by the following organizations;
•Occupational Safety and Health Administration (OSHA)
•National Institute for Occupational Safety and Health (NIOSH)
•The Joint Commission
•Centers for Disease Control and Prevention (CDC)
• International Sharps Injury Prevention Society (ISIPS)34
A summary of the Standards are as follows:
Standard of Practice I A neutral zone should be utilized during all surgical procedures to prevent two individuals from simultaneously handling a contaminated sharp, including, but not limited to scalpel blades, suture needles, hypodermic needles, and sharp surgical instruments.
Standard of Practice II If the procedure necessitates reuse of a hypodermic needle multiple times on the same patient, recap the hypodermic needle between uses, utilizing a one-handed approach or a safety device that enables one-handed recapping.
Standard of Practice III A sterile sharps container should be used on every case to store used sharps.
Standard of Practice IV When organizing the sharps in the work area (e.g. Mayo stand or back table) the sharps should be pointed away from the handler and receiving personnel.
Standard of Practice V Visually inspect the field and all waste material for the presence of sharps beforedisposal.
Standard of Practice VI Utilize mechanical safety devices to remove or attach blades, needles or other sharps.
Standard of Practice VII The routine use of double gloving by all surgical sterile team members is recommended for all surgical procedures.
Standard of Practice VIII A nonsterile sharps container must be used for the disposal of all needles and other sharps to decrease the risk of injury to HCWs and patients.
Standard of Practice IX Reusable sharps should be transported to the central sterile processing department in a puncture-resistant closed container.
Standard of Practice X Policies and procedures for the safe handling of sharps and use of hands-free techniques should be periodically reviewed and when necessary, revised to reflect current safe practices. Perioperative personnel should complete continuing education to remain current in their knowledge of safe practices in the O.R.35
(To see the standards in their entirety see http://www.ast.org/pdf/Standards_of_Practice/RSOP_Sharps_Safety_Neutral_Zone.pdf)
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RESISTANCE TO CHANGE It is acknowledged that any change is difficult. Changing something about your surgical routine is not easy. Common objections to trialing new products that have sharp safety mechanisms are as follows;
Denials of occupational risk Often times claims are that the risk is low, it is part of the job, or that they are always careful with sharps. It doesn’t and shouldn’t have to be part of the job when solutions are available.
Failure to consider risk of their behavior to OR teammates and others Sometimes people on the team forget about the risk for the other team members.
No surgeon accountability for preventable injuries
Safety devices not acceptable. With so many new options available to trial, there is no excuse not to protect yourself, the patient and those working around you.
Continued access to conventional sharps items
Lack of multidisciplinary support Sometimes it is difficult to get the multidisciplinary support that you need to implement sharps safety practices and the safest products in your facility.
It is important to note—Exposure control plans should document annual consideration and implementation of appropriate* commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.
*Appropriate = Devices that will not jeopardize the patient or employee safety. If it is determined unsafe, then it must be clearly documented and
justified in the annual exposure control plan.
FACTS AND STATISTICS There are numerous sources of sharps injury data. Needlestick injuries are not the only means of injury. Sharps injuries can result from the uses of many different instruments including, but not limited to, hollow bore needles, suture needles, scalpel blades, broken glass, wire sutures, guide wires, stylets, scissors and lancets. As a result of percutaneous and/or mucocutaneous exposures all HCWs can be at risk for a number of maladies.
Accidental needle stick injuries can lead to the following risk of infection;
•0.3% transmission of HIV infected blood37
•30% for Hepatitis B virus37
•10% for Hepatitis C virus37
Sharps injuries can lead to viruses, fungi, bacteria, and other microorganisms. These diseases include:
•Mycobacteriosis
•Brucellosis
•Malaria
•Blastomycosis
•Rocky Mountain spotted fever
•Cryptococcosis
•Cutaneous gonorrhea
•Diphtheria
•Tuberculosis
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•Syphilis
•Herpes
•Mycoplasma caviae
•Sporotrichosis
•Streptococcus pyogenes
•Staphylococcus aureus
•Toxoplasmosis
The International Sharps Injury Prevention Society (ISIPS) offers numerous facts and statistics in their monthly newsletter. They reveal the continued need for improvement and attention when discussing this issue.
OSHA estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodborne pathogens.38
CORRECTIVE MEASURES
In order to reduce or eliminate the hazards of occupational exposure to bloodborne pathogens, an employer must create and implement an exposure control plan for the worksite with details on employee protection measures. It is essential that the plan describes how an employer will use a mixture of the following to ensure the safety of the patients and employees in the department.
•Training and education on the use of safer medical devices and safer work practices.
•Staff involvement in the device selection and evaluation process, particularly as new safer devices are introduced into the work setting.
•Organization of the work area so that the sharps are always pointed away from staff members and establishment of a separate area to place a reusable sharp for safe handling during the procedure.
•Use of needleless systems (a device that does not use needles) for: (1) The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; (2) The administration of medication or fluids; or (3) Any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.
•Use of a neutral zone or hands-free technique (HFT) to designate a sharps neutral zone (for example a towel, Mayo stand, magnetic pad or friction mat) for the pickup and placement of surgical sharps such as needle-holders, scalpels, and syringes with needles. In this manner, there is never direct handing of instruments from scrub person to surgeon and back. If the surgeon must not break eye contact with the surgical field during critical parts of the operation where patient safety or workflow might be compromised, a partial HFT may be used whereby sharps are directly handed by the scrub person to the surgeon, but then returned to the scrub person via a neutral zone.
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•Engineered Sharps focus attention on the intent of the action when working with sharp items, and minimize rushing and distractions while applying safety techniques during critical moments.
•Blunt Tip suture Needles for the closure of fascia and muscle in order to reduce needle-stick injuries in surgeons and OR personnel.
•One handed or instrument-assisted suturing technique to avoid contact with the needle.
•Double gloving in order to reduce body fluid exposure due to glove tears and sharps injuries in surgeons and scrub personnel.
•No two-handed recapping of syringes. One handed recapping is allowed if it is required by a specific medical procedure. This must be justified in writing in the exposure control plan, a device is recommended to accomplish the one handed recapping and the employee must be trained.
•Use of Engineered Sharps Injury Prevention (ESIP) products. This means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.
•Provide ease of ordering and good selection.
•Establish and enforce an OR sharps policy that covers engineering and work practice controls.
• Identify one or more champions that will help continue safe practice for your staff and surgeons.
• Incorporate this training and education into resident and staff and annual orientation training.
COMPLIANCE AND OSHA INSPECTION INFORMATIONCOMPLIANCE - A SNAPSHOT
A survey conducted by AORN in August 2011, sampling a random group of AORN members in hospitals and ASC settings provided the following eye opening numbers concerning sharps;
•57% said their facilities have implemented a sharps injury prevention education plan.
•70% said they double glove.
•55% said there is a lack of multidisciplinary support.
•61% said surgeon support can help to reach a consensus for implementation.39
INSPECTIONS
It is important to note that all OSHA compliance inspections are unannounced. However a facility can ask for Compliance Assistance (consultation) inspections and, under this situation, it would be scheduled at the request and convenience of the employer. No citations or penalties would be cited under this circumstance.
Because OSHA oversees 7 million workplaces, compliance inspection scheduling is done according to priority.
– Imminent Danger- The employer must fix this situation immediately or remove the endangered employees.
– Fatalities/Catastrophes- A fatality is when one or more employees is killed and a catastrophe is when three or
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more employees are hospitalized in an incident. The employer must contact OSHA within eight hours of the occurrence(s).
– Complaints/Referrals- The employee can do this anonymously. Claims of hazards, risk or violations receive high priority. Complaints are from employees or their representatives. Referrals are from other government agencies or the media.
– Programmed Inspection- These are inspections intended for a specific industry with high hazards or individual workplaces that have experienced high rates of injuries or illnesses.
– Special Emphasis Programs/ Targeting Initiatives- Such as OSHA’s Region 4 Emphasis Program for needlestick and sharps injuries40
OSHA has a presence in many industries but healthcare has not been a large emphasis in the past. In an effort to improve compliance in healthcare and provide better service to HCWs, OSHA implemented a Regional Emphasis Program (REP) effective March 25, 2011. The purpose of this REP is to reduce the number of sharps injuries in ambulatory care, freestanding ER clinics and primary care clinics. This program is in Region 4 and while there are eight states in the region, four have state programs (South Carolina, Tennessee, Kentucky, and North Carolina), and the other four (Georgia, Alabama, Mississippi and Florida) will have OSHA surveyors visiting. Under this program OSHA will evaluate the employer’s BBP Exposure Plan especially as it relates to protecting employees from needlestick and sharps hazards.
Tennessee OSHA has developed a targeting initiative and is inspecting hospitals and ambulatory surgery centers in Tennessee to determine compliance with the Needlestick Safety and Prevention Act.
CITATIONS
Citations can be issued for all apparent violations of standards and regulations during compliance inspections. You will receive a citation for first incidence of violation. Most bloodborne violations are classified as “serious” according to the compliance directive (CPL 02-02-069). As seen below, citations for serious violations are accompanied by monetary penalties, starting with an unadjusted penalty of $7,000 per violation. These are issued within 6 months (usually less) of the violation.41
CITATION GUIDELINES
The following is a comprehensive list of items that can be cited.
(c)(1)(ii)(c)- Failure to include procedures for the evaluation of exposure incidents in the exposure control plan.
(c)(1)(iv)- No review and update of the Exposure Control Plan, as necessary, to reflect changes in technology, such as the use of effective engineering controls that can eliminate or minimize exposures.
(c)(1)(iv)(B) – Did not document annual consideration and implementation of safer medical devices.
(c)(1)(v) – Exposure Control Plan did not solicit and document front line employee input in the selection of sharps with engineered sharps injury protection.
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(d)(2)(i) – Engineering and work practice controls were not used to eliminate or minimize employee exposure.
(d)(2)(ii) – The employer did not have a system for regular checking of the engineering controls to ensure that safer devices function effectively.
(d)(2)(vii) – Removing, bending, shearing, or recapping needles.
(d)(2)(vii)(A)-Bending, recapping or removal of contaminated sharps without demonstrating and documenting that no alternative is feasible or that it is required by a specific medical procedure.
(d)(2)(vii)(B)-Removing a needle or sharp (such as a scalpel blade) without using a one-handed technique.
(d)(2)(viii)(A)-(D)-Inappropriate containers for contaminated reusable sharps.
(d)(4)(ii)(E) –Reaching by hand into containers of contaminated reusable sharps.
(d)(4)(iii)(A)(1)-Contaminated sharps not discarded immediately.
(d)(4)(iii)(A)(2)(i)-Sharps containers not located as close as feasible to the immediate area where sharps are used.
(d)(4)(iii)(A)(2)(ii)-Sharps containers not maintained upright throughout use.
(d)(4)(iii)(A)(2)(iii) – Sharps containers overfilled.
(d)(4)(iii)(A)(3)(i)-Sharps containers not closed when moving.
(d)(4)(iii)(A)(4)-Sharps containers opened or emptied.
(f)(1)(i)-Hepatitis B vaccination not made available to employees with occupational exposure.
(f)(2)(iv)-Employees who declined the Hepatitis vaccination did not sign a declination form.
(f)(3)(v)-Post-exposure evaluation did not include counseling.
(f)(3)(I)-Failure to conduct an evaluation of exposure incidents following procedures established in Exposure Control Plan.
(f)(4)(ii)-Healthcare professional evaluating an employee after an exposure incident was not provided the required information.
(f)(5)-Healthcare professional’s written opinion not obtained and provided to the employee within 15 days of post-exposure evaluation.
(g)(2)(i)-Training for employees with occupational was not at no cost to the employee and/or during working hours.
(g)(2)(ii)(A)-Initial training was not conducted at the time of assignment
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(g)(2)(iv)-Annual training not provided within one year of the previous training.
(g)(2)(vii)(F) –Training did not include the use and limitations of engineering controls.
(h)(1)(i) thru (iv) –Deficient medical records maintained.
(h)(2)(i)(A-D)-Training records did not include date conducted, qualifications of the trainer, summary of training session and name and job title of attendees.
(h)(5) – Sharps log did not have all required information. (all sharps injuries must be logged even for employees of other employers working on site).42
Willful: A willful violation exists under the OSH Act where an employer has demonstrated either an intentional disregard for the requirements of the OSH Act or a plain indifference to employee safety and health. Penalties range from $5,000 to $70,000 per willful violation.43
Serious: Section 17(k) of the OSH Act provides that "a serious violation shall be deemed to exist in a place of employment if there is a substantial probability that death or serious physical harm could result from a condition which exists, or from one or more practices, means, methods, operations, or processes which have been adopted or are in use, in such place of employment unless the employer did not, and could not with the exercise of reasonable diligence, know of the presence of the violation." OSHA may propose a penalty of up to $7,000 for each violation.44
Also if you receive a Citation and Notification of Penalty, you must post the citation (or a copy of it) at or near the place where each violation occurred to
make employees aware of the hazards to which they may be exposed. The citation must remain posted in a place where employees can see it, for three working days or until the violation is corrected, whichever is longer. (Saturdays, Sundays, and Federal holidays are not counted as working days.) You must comply with these posting requirements even if you contest the citation.
BENEFITS TO COMPLYING WITH SHARPS SAFETY
Complying with sharps safety practices
is the source to managing the success of
your patient and healthcare staff safety
goals. There is much work to be done to
eliminate these issues in healthcare but if
you follow the solutions above you should
see the following:
•Reduced sharps injuries by 62% to 88%45
•Decreased exposure to life threatening bloodborne pathogens
•Reduced workers compensation claims/costs
•Reduced liability claims
•Reduced lost work days
•Decreased staff fear of exposure while improving patient safety and staff satisfaction
Sharps safety is not the only safety issue that confronts HCWs in the operating room today…
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ERGONOMIC WORKPLACE SAFETYErgonomics in the healthcare setting is likewise receiving the attention of regulators, both state and federal. Ergonomics by definition is the "scientific study of the efficiency of people in the workplace," coined in 1950, from Gk. ergon "work" (see urge (v.)) + (ec)onomics.46 Ergonomics attempts to fit the workplace to the worker. In the healthcare setting everything from floor coverings to the height of work surfaces has a role in helping to maintain good and supportive functionality for the worker. Of particular importance is the issue of moving and lifting patients and equipment. NIOSH identifies back injuries as the second leading injury in the US. And back pain is the most common reason for filing worker compensation claims.47
A work related injury can potentially affect every aspect of your life. Musculoskeletal disorders are one of the most frequent and costly types of occupational injuries affecting nurses.48 Nurses have the highest claim rates of any occupation or industry. Back injuries account for more than 36% of the musculoskeletal injuries reported.49 Injuries from lifting, tripping, falling, etc. are reported under Worker Compensation (WC) claims as musculoskeletal disorders (MSDs) and employers pay more than $15-20 billion in Workman’s Compensation per year.50 The extent of musculoskeletal disorders among the U.S. nursing workforce is particularly distressing when considered in the context of the current nursing shortage. It is estimated that 12% of nurses leave the profession annually due to back injuries and greater than 52% complain of chronic back pain.51
No-Lift Laws As a result of these costs, claims and risks a number of states have enacted “No Lift” laws. Texas was the first to pass such legislation, which required hospitals and nursing homes to implement a safe patient handling and movement program. The Texas law took effect Jan. 1, 2006. Since then, approximately ten states have followed suit and another ten have introduced legislation.
The legislation has common elements that include programs restricting or eliminating manual lifting of patients, tax credits for purchasing lifting and related devices, programs that evaluate risk, and evaluation of the program.
HUMAN FACTORS INCREASING THE RISK OF ERGONOMIC MISHAPS It’s not only unsafe workplace conditions, human factors can be added to the risk of slips, trips and falls occurring. Be aware of demands of work tasks and the capabilities of each worker. A worker's ability to perform work tasks may vary because of differences in age, physical condition (eye site, fatigue or stress), strength, gender, stature, and other factors. A staff member may have health and/or physical conditions that they may need to compensate for by taking safety measures.
UNSAFE WORK CONDITIONSEach and every department is responsible for ensuring the safety of their staff. The following need to be taken into consideration to ensure that the staff is protected and that they work in an environment that is safe for them and their patients;22
•Do not carry too many cumbersome objects
•Use a cart to do the work for you
•Be aware of objects that may obstruct your view
•Watch for cluttered hallways or wet floors
•Use signs to identify hazards
•Discourage inattentive behavior
•Avoid taking shortcuts
Potential Risk Factors
•Excessive reaching
•Pushing or pulling
•Bending
•Awkward posture or position
•Excessive weight load
•Forceful tasks (e.g., pushing a stretcher and patient up a ramp)
•Repetitive motion (e.g., passing instruments, opening suture packets, typing)
• Awkward posture (e.g., holding retractors during a surgical procedure, lifting or holding patient extremities)
•Static posture (e.g., standing for long periods of time in one position)
•Moving or lifting patients and equipment (e.g., lifting without assistance)
•Carrying heavy instruments and equipment (e.g., removing a sterilized tray of instruments from the autoclave), and;
•Overexertion (e.g., protecting a combative patient emerging from anesthesia).
REGULATORY ORGANIZATIONS INFLUENCE– ERGONOMICSOSHA STANDARDS
According to the Bureau of Labor Statistics, employees in nursing and personal care facilities suffer over 200,000 work-related injuries and illnesses each year. Many of these are serious injuries, with more than half requiring time away from work. Worker's compensation costs for the healthcare industry now amount to nearly one billion dollars per year.52
OSHA offers an ergonomic tool kit in order to provide additional education and training on this subject. They also help regulate ergonomic safety to ensure that each employee feels safe in their workplace.
OSHA states, “Each employer shall furnish to each of his employees a place of employment which is free from recognized hazards that are causing, or are likely to cause, death or serious physical harm to his employees”.53
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They also state that the, “Manual lifting of residents be minimized in all cases and eliminated when feasible. Employers [should] implement an effective ergonomic process that: provides management support; involves employees; identifies problems; implements solutions; addresses reports of injuries; provides training; and evaluates ergonomics efforts”.54
NIOSH
NIOSH states, “Ergonomics is the scientific study of people at work. The goal of ergonomics is to reduce stress and eliminate injuries and disorders associated with the overuse of muscles, bad posture, and repeated tasks. This is accomplished by designing tasks, work spaces, controls, displays, tools, lighting, and equipment to fit the employee’s physical capabilities and limitations.”
Nursing professionals display high rates of back and shoulder injuries. In 2009, more than 23,000 lost-time cases of work-related back pain, carpal tunnel syndrome, and tendonitis were reported in the Healthcare and Social Assistance sector (HCSA) by BLS; of these, more than 44% were among healthcare support occupations such as aides and assistants. In 2009, nursing aides and orderlies, registered nurses, and licensed practical nurses suffered the highest prevalence (16.6%) and reported the most annual cases (n=3,620) of work-related back pain involving days away from work in the HCSA sector.55
The Joint Commission
Standard EC.1.10 The hospital manages safety risks. Elements of Performance: The hospital conducts proactive risk assessments that evaluate the
potential adverse impact of buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff and other people coming to the hospital’s facilities… and the hospital uses the risks identified to select and implement procedures and controls to achieve the lowest potential for adverse impact on the safety and health of patients, staff and other people coming to the hospital’s facilities.56
Standard EC.9.10 The hospital monitors conditions in the environment. Elements of Performance: The hospital monitors conditions in the environment including injuries to patients or others coming to the hospital’s facilities as well as incidents of property damage and occupational illnesses and injuries.57
Ergonomic Facts and Statistics
•12%-18% will actually leave the nursing profession due to chronic back pain.58
•Nursing aides and orderlies suffer the highest prevalence (18.8%).59
•Direct costs associated with occupational back injuries of health care providers average $37,000 per injury.60
• Indirect costs associated with back injuries can range from $147,000 to $300,000. 6.1% of private sector employees suffered 5.7 million workplace injuries and illnesses. 46% of those injury cases required days away from work for recuperation or restricted work activity.61
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•A total of 626,000 lost workdays due to musculoskeletal disorders (MSDs) are reported to the Bureau of Labor Statistics, accounting for $1 of every $3 spent for workers’ compensation in that year.62
•Work-related injuries potentially affect every aspect of life (e.g. ability to perform all functions of your job, leisure activies, your mobility in your later years.)
•Work-related musculoskeletal disorders (MSDs) currently account for one-third of all occupational injuries and illnesses reported to the Bureau of Labor Statistics (BLS) each year.63
•Research demonstrates that specific interventions can reduce the reported rate of musculoskeletal disorders for workers who perform high-risk tasks.64
•Employers pay more than $15-$20 billion in workers’ compensation costs for musculoskeletal disorders (MSDs) every year.65
•Falls (fatal and nonfatal) are a serious safety concern in the workplace, taking 715 lives and inflicting 313,335 injuries involving a work absence in one year.
•The most common workplace accidents are slip and trip injuries.
•Same level falls, like slips and trips, account for 65% of all fall-related injuries.
•The average claim costs are $11,771. When you factor in all other costs such as staff replacement, lost productivity and equipment damages, the estimated actual cost to a company can be as much as four times the claim costs –approximately $59,000 per injury.
•Slip and trip injuries represent the most common type of major employee injury, rising from 33% in 2000/2001 to 37% in 2001/2002.
•Overexertion, repetitive stress injuries and falls while on the job cost more than $6 billion in lost wages, health care expenses, legal costs and workers’ compensation claims.
•Occupational hazards in the workplace have been identified as a major contributor to nurses leaving the profession, contributing to the growing nursing shortage.
PROFESSIONAL ORGANIZATIONAL INFLUENCE– ERGONOMICS AORN POSITION STATEMENT
AORN has included safe patient guidance in the 2011 Recommended Practices. This is a comprehensive tool designed to help decrease or eliminate musculoskeletal disorders for the perioperative nurse.66
“AORN is committed to the attainment and maintenance of an ergonomically healthy workplace to protect all employees in the perioperative setting. Therefore, AORN believes that every organizational perioperative setting should be ergonomically safe to decrease or prevent injury to the health care worker. Safe working conditions must be a top priority for all health care organizations. Each organization's leadership team should assess, identify, develop, and implement risk reduction strategies for injury prevention using an ergonomic approach. AORN supports research
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that is directed toward creating and maintaining equipment and work tasks to conform to the capability of the perioperative health care worker. AORN further supports collaboration with the National Institute for Occupational Safety and Health, Occupational Safety and Health Association, and state and local regulation to promote ergonomic safety in the perioperative environment.”67
AORN believes that risk-reduction strategies in the following areas should be considered when developing a plan for an ergonomically healthy perioperative environment.68
Administrative Controls
•Develop a culture of ergonomic safety.
•Develop and implement a policy for manual patient handling.
•Develop and implement patient care ergonomic assessment protocols.
•Limit the weight of instrument trays.
•Educate and train staff in the use of patient handling devices and strategies to prevent musculoskeletal injury.
•Design and implement ergonomic work stations.
Engineering Controls
•Maintain adequate room lighting.
•Have available appropriate assistive patient handling equipment.
•Adapt workstations, tools, and equipment for ergonomic safety.
Behavioral Controls
•Have available ergonomic clinical advisors and/or resources.
•Wear nonskid footwear.
•Remove or eliminate clutter.
•Keep cabinet doors and room doors closed.
•Clean up spills or debris immediately.
•Cover equipment cables across the floor.
•Use lift teams to handle patients.
• Inspect furniture wheels frequently for buildup of debris.69
AST Recommendation
The following Recommended Standards of Practice were researched and authored by the AST Education and Professional Standards Committee and have been approved by the AST Board of Directors. According to AST, Surgical team members should follow ergonomic principles for positioning patients.70
1. The surgical technologist should be aware of the following poor body mechanics that can lead to neck, shoulder, back and knee injuries:
•Lifting with the back bowed out
•Bending and reaching with the back bowed out
•Jerking or twisting at the hips
•Obesity
•Loss of strength and flexibility
•Poor nutrition
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2. One of the more difficult tasks for the surgical team is moving and positioning an incapacitated/immobile or anesthetized patient. The surgical technologist should practice proper body mechanics in preventing injury and discomfort when assisting with positioning the patient.
A. Proper body mechanics to implement when positioning the patient include the following (Orthopedics International – Spine):
(1) Stand with legs approximately shoulder width apart to give the body a solid stance and allow the ligaments of the hips and knees to support the body.
(2) Avoid weight bearing on one leg and foot.
(3) Stand in front of and as close to the patient and/or body part.
to be positioned when moving or in other words, keep the weight as close to the body as possible.
(4) Tighten the stomach muscles to help support the back.
(5) Do not twist at the hips while lifting; if a turn must be made, turn the whole body if possible, but not at the waist.
(6) Lift using leg muscles.
(7) Lift or move the patient with a smooth, even motion in sequence with surgical team members; avoid jerking movements.
(8) Bow the back in, keeping the heels flat.
(9) Keep the lower back bowed in when lowering the patient or body part.
(10) Push, do not pull heavy equipment such as the OR table.
3. A sufficient number of surgical personnel should assist in moving and positioning a patient.
A. Additional personnel should assist in moving and positioning the obese patient.
4. OR tables are heavy and difficult to maneuver, placing the surgical team at risk for injury.
A. The surgical technologist should not attempt to move an OR table alone, but have assistance from at least one other surgical team member.
(1) The surgical technologist must confirm the OR table wheels are in the unlocked position prior to moving. If the wheels are in the locked position and a surgical team member attempts to move the bed assuming the wheels are unlocked, it can cause a body injury due to the harsh jerking movement that can occur upon pushing on the table.
5. It is recommended the surgical team use a roller or other type of mechanical lifting device when placing the patient on the OR table from the stretcher.
A. A mechanical lifting device should be used for morbidly obese patients to avoid injuries to the patient and surgical team.70
Primary Solutions – Work Practice Controls A clear process must be established when striving to eliminate workplace safety hazards. First determine where potential safety issues exist in your department.
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Then, identify and prioritize the greatest risk(s). Formulate a plan and implement new procedures. Evaluate your situation on an annual regular basis. Eliminate/reduce risk factor(s) by doing the following:
•Develop a culture of ergonomic safety.
•Develop and implement a policy for safe work practices.
•Educate and train staff in the safe work practices of ergonomics.
•Maintain adequate room lighting.
•Have available appropriate assistive patient handling equipment such as lateral transfer device.
•Adapt workstations, tools, and equipment for ergonomic safety such as
– Anti-Fatigue Mats on floors
– Anti-Fatigue Mats on stools
– Sit-Stand chair at correct height
•Have available ergonomic clinical advisors and/or resources.
•Wear appropriate clothing and footwear to protect yourself.
•Remove or eliminate clutter.
•Keep cabinet doors and room doors closed.
•Clean up spills or debris immediately.
•Cover equipment cables across the floor to protect employees from tripping and falling over them.
•Use lift teams to handle patients.
•Have equipment inspected on a regular basis and for any issues that might cause harm.
BENEFITS OF COMPLYING WITH ERGONOMIC SAFETY
Working in the healthcare field may expose workers to physical conditions (e.g., Excessive reaching, pushing, pulling, bending, awkward posture or position, lifting excessive load force, and repetitive motions) that can lead to injuries, wasted energy, and wasted time. To evade these problems, you and your organization need to promote safe working conditions. Making safety changes in your workplace can benefit you and your employer by:
•Reducing or preventing injuries.
•Reducing workers’ physical strain by decreasing forces in lifting, handling, pushing, and pulling.
•Reducing risk factors for musculoskeletal disorders.
• Increasing productivity, product and service quality, and worker morale.
•Lowering costs by reducing or eliminating production use of medical services because of musculoskeletal disorders, workers’compensation claims, excessive worker turnover,
absenteeism, and retraining.
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SUMMARY
Occupational exposure to bloodborne pathogens via percutaneous injuries is one of the most serious dangers perioperative team members face on a daily basis. The risk of sustaining a percutaneous injury can be reduced through employee education, clear communication, implementation of engineered devices, and focused work practice controls.
Musculoskeletal disorders in the healthcare setting are frequent and costly to the profession. To improve the workplace conditions and the health and wellbeing of healthcare workers is an ongoing process of education and training in all aspects of
ergonomic safety. Facilities should comply with regulatory requirements for adoption of safer surgical technologies, and promote policies and practices that have shown to reduce blood exposure and musculoskeletal injuries. There is further work and ongoing vigilance to be vested in the process to impact these issues in healthcare. We each have a responsibility to our colleagues to do so.
Additional resources such as AORN Sharps Safety Tool Kit, NIOSH/CDC Stop Sticks Campaign and AORN Safe Patient Handling and Movement the Tool Kit to assist you in your efforts can be found online.
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