Recently, one of this article’s coauthors had a nuclear medicine scan at an outpatient facility. She noticed the nurse used extreme caution when handling the syringe and needle loaded with the radioactive isotope, which had been carried in a lead box and handled with great care. But after the nurse administered the isotope, she used her bare hands to recap the conventional, hollow-bore needle that had just been in the patient’s vein.

How could this situation arise, in violation of the Needlestick Prevention Act—especially when handling such a highly contaminated device? This law applies to nonhospital settings as well as hospitals. In search of answers to questions like this, we conducted a survey of nonhospital workers to learn more about their unique issues. This article summarizes survey results and describes steps workers in nonhospital settings can take to reduce their risk of exposure to bloodborne pathogens.

Defining the problem

As more health care is delivered outside of hospitals to sicker patients undergoing more invasive procedures than ever, the need to reduce needlestick injuries in these settings is emerging as a key occupational safety issue. By a conservative estimate, about 40% of the nation’s 2.3 million registered nurses are employed in nonhospital settings.

In 2001, the Occupational Safety and Health Administration (OSHA) published and began enforcing a revised version of the bloodborne pathogens standard (BPS). Since then, use of safety-engineered devices has risen significantly. (See How OSHA defines safety-engineered devices.)

The Centers for Disease Control and Prevention estimates that more than 380,000 parenteral blood exposures occur annually in U.S. healthcare workers. This means about 1 in 10 healthcare workers experiences a needlestick injury each year. Underreporting of needlesticks continues to hover around 40%.

The good news: The BPS has brought a significant reduction in hospital needlestick injuries. With hospitals generally moving in the right direction, needlestick prevention efforts have started to focus on nonhospital healthcare facilities, where such injuries are harder to track and injury rates are less well known. Nonhospital facilities encompass a wide variety of settings, including ambulatory and home care; outpatient, occupational health and public health clinics; surgery, dialysis, and rehabilitation centers; correctional facilities; nursing homes; and dental, medical, and nursing offices.

Some nonhospital employers may believe they’re exempt from the BPS because of their facility’s small size. However, all healthcare employers, including medical or dental offices and small clinics, are required to comply with the standard. Noncompliance puts healthcare workers at risk and can be costly to employers. Besides incurring OSHA fines (which can run into thousands of dollars), an occupational injury or infection can increase employers’ costs by:

• raising insurance rates, especially for self-insured employers
• increasing workers’ compensation payouts
• necessitating legal fees to defend against lawsuits by an injured worker or the worker’s union
• causing lost time at work by injured or exposed employees who need treatment and follow-up
• requiring the hiring of temporary or permanent replacement workers
• bringing negative publicity, which can damage the employer’s reputation.

On the other hand, complying with the BPS can bring multiple benefits, such as avoiding the increased costs described above and promoting a culture of safety that helps employers stay competitive in recruiting and retaining skilled employees. These factors should provide ample motivation for employers to get on board and improve their compliance with OSHA regulations.

Survey of healthcare professionals in nonhospital settings

Reaching nonhospital nurses can be challenging, as many work in small clinical settings or as sole practitioners. So when the International Healthcare Worker Safety Center at the University of Virginia sponsored a webinar (“Achieving sharps safety compliance in nonhospital healthcare settings”) in August 2011, the authors took the opportunity to conduct a follow-up survey of participants to gather information on their attitudes toward and knowledge of needle safety and sharps injury prevention. After the webinar, we e-mailed the 571 registrants an invitation to take an online survey; of those contacted, 218 (38%) completed the survey. The resulting data, although not based on a statistically derived sample, provide interesting insights on sharps safety in nonhospital settings. Below are the survey questions and a summary of our findings:

• What is the best description of your worksite? Respondents worked in a wide variety of settings. The most common were physician offices, outpatient clinics, ambulatory care, and occupational health settings, followed closely by surgery centers and long-term care/rehabilitation centers. The largest occupational group in the survey (n = 62) identified themselves as nurses. Other occupations represented were administrators (n = 41), infection-control practitioners (n = 38), safety professionals (n = 35), and educators/trainers (n = 31).
• Does your facility routinely use safety-engineered devices that protect healthcare workers from needlestick injuries? Almost 98% of respondents were aware of the BPS requirement to use safety-engineered devices. More than 96% of those with direct patient contact said they always or usually used safety-engineered devices, and about 90% indicated they always or usually were involved in selection of new devices. But nearly 10% said they were rarely or never involved in selection. OSHA requires that nonmanagerial employees responsible for direct patient care have input into device selection. This should be a focus for compliance improvement efforts in nonhospital settings.
• Do you feel confident in your ability to evaluate new safety-engineered devices that might be appropriate in your facility? Less than half of the respondents who were involved in evaluating new devices felt completely confident in their ability to evaluate them. More than half (59.7%) responded they would like resource tools to be made available and/or would like to receive more training on this process. Clearly, this is an area of need.
• What do you think are some of the barriers to using safety-engineered devices in nonhospital healthcare facilities? Encouragingly, about 30% of respondents indicated they saw no barriers to using such devices in their workplaces, and said they used only safety devices. But nearly 20% said their managers (owners, physicians, or dentists) don’t consider use of these devices to be a priority. Almost one-third agreed that the higher cost of the devices is prohibitive compared to that of conventional nonsafety devices. Another 17% indicated that the safety-engineered devices currently available don’t meet their clinical needs. Only six respondents perceived the risk of exposure to bloodborne patho­gens in nonhospital settings as low.

Analysis

Survey respondents, who represented a wide range of nonhospital healthcare settings, were fairly well-educated about needlestick prevention and BPS requirements. Many already were involved in sharps safety efforts in their facilities. Still, their responses clearly indicate some areas where more work is needed.

Responding to a needlestick

When needlesticks occur in nonhospital settings, responding in a timely and appropriate manner is important—although it can be challenging at times. The perception that workers in nonacute-care healthcare settings are at lower risk for bloodborne pathogen transmission than hospital workers is incorrect. Experts agree that the location or clinical setting of a needlestick isn’t relevant in assessing transmission risk. What matters is the type of device used (for example, a hollow-bore needle) and nature of the injury (for example, contamination of the device with blood). OSHA requires employees to receive immediate evaluation and follow-up treatment, as appropriate, by a qualified provider after blood exposure, regardless of the healthcare setting.

Action items

Nurses and professional organizations need to renew efforts to reduce needlestick injuries in nonhospital settings. Consider taking the following actions:

• Increase your involvement in selection of safety-engineered devices. The BPS—and common sense—dictate participation of nonmanagerial, direct-care nurses. Personnel who use these devices should have a voice in their selection. So take an active interest and get involved in the selection process.
• Use device evaluation resources to help find and evaluate safety-engineered devices. Many online resources are available, but workers in nonhospital settings may be unaware of these. Professional organizations for providers in these settings can play a role in getting this critical information to members.
• Hold employers, managers, and small-practice owners accountable for meeting BPS requirements. OSHA is clear that employers have a responsibility to evaluate and implement safety-engineered devices. The agency doesn’t exempt employers from providing safety-engineered devices on the grounds of cost. File a complaint if your employer doesn’t respond to safety concerns, and expect OSHA to respond. Call 1-800-321-OSHA (6742) for information on how to file a complaint.
• Look for opportunities to collaborate with manufacturers and researchers to ensure new devices meet the unique needs of nonhospital settings. Many nonhospital settings present unique challenges in healthcare delivery. They may be poorly lit, involve unruly or violent patients, require clinicians to practice in isolated settings with scarce resources, or involve complex procedures previously done only in hospitals. Nurses can provide critical input into device design and selection so their clinical needs are taken into account.
• Know your facility’s plan for needlestick injury response. Many nonhospital health services are delivered in community-based settings where access to prompt treatment can be challenging. Optimally, evaluation and treatment should occur within 2 hours of a needlestick. Be sure you know how to get prompt and proper care. If you have questions about treatment for a needlestick injury, call the National Clinicians’ Post-Exposure Prophylaxis hotline (PEPLine) at 1-888-448-4911, available daily from 9 a.m. to 2 a.m. EST.

By working together with professional organizations, manufacturers, researchers, educators, and regulators, we can improve the safety and health of all workers in nonhospital settings.

Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.

Elise Handelman is an occupational and environmental health consultant in Annapolis, Maryland. Jane L. Perry is associate director of the International Healthcare Worker Safety Center at the University of Virginia Health System, Charlottesville. Ginger Parker is EPINet database manager at the International Healthcare Worker Safety Center.

To read another article from this supplement, Moving the Sharps Safety Agenda Forward, please click below:

To reduce sharps injuries, all of us must create a culture of safety in our workplaces

Essential elements of a comprehensive sharps injury-prevention program

Practical strategies to prevent surgical sharps injuries

Moving the Sharps Safety Agenda Forward: Consensus Statement and Call to Action

Choosing wisely: Resources for selecting sharps safety devices