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

2. At the end of 2000-globally There was an estimated: 36.1 million persons with HIV/AIDS Adler, Mw, ABC of AIDS development of the epidemic. BMJ. May 19, 2001,322 (7296) 1226-1229

3. In the U.S. at the end of 2000 There was an estimated 340,00 persons living with AIDS. Klevens, RM and Neal, JJ. Update: AIDS United States, CDC MMWR Weekly. July 12, 2002/51(27); 592-595

4. At the end of 2003 An estimated 1 million persons are living with HIV infection in U.S. Due the highly active antiretroviral therapy (HAART) since 1996, persons with HIV are living longer and the progression to AIDS has lessened. Espinoza, L. et al. Trends in HIV/AIDS diagnosis—33 states, 2001-2004. MMWR Weekly. November 18, 2005/54 (45); 1149- 1153

5. CDC Recommendations after a 33 state study Adopt confidential, name-based surveillance systems that report HIV infections because AIDS surveillance no longer provides an accurate population- based monitoring of the epidemic. Espinoza, L. et al. Trends in HIV/AIDS diagnosis—33 states, 2001- 2004, CDC MMWR Weekly. November 18, 2005/54 (45); 1149- 1153.

6. Global BBP Among Health Care Workers Reports of global BBP infections among an estimated 35 to 100 million health care workers is fortunately small in comparison to risk: 65,000 Hepatitis B infections 16,400 Hepatitis C infections 1000 HIV infections Puro, V. and Shouval, D. Conclusions of the meeting of the Viral Hepatitis B, Hepatitis C, and other bloodborne infections in health care workers. Rome, Italy, March 17-18, 2005. Viral Hepatitis. November 2005 14 (1) 1-16.

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

8. BBP Risk With Percutaneous Injury.3% risk for contracting HIV with device contaminated with HIV 1.8% risk for Hepatitis C if device is contaminated with HCV Hepatitis C is the most frequent infection resulting from sharps injuries Rosenstock, Linda. Statement for the Record on Needlestick Injuries. National Institute For Occupational Safety and Health Centers for Disease Control and Prevention U.S. Department of Health and Human Services before the House Subcommittee on Workforce Protection Committee on Education and The Workforce, June 22, 2000.

9. Hepatitis C Called the silent epidemic 70-80% of persons infected will develop active liver disease over a period of years –10-20% cirrhosis –1-5% of cirrhosis cases will develop liver cancer Treatment is about 50% effective Rosenstock, Linda. Statement For the Record on Needlestick Injuries. NIOSH and Health Centers for Disease Control and Prevention U.S. DHHS Before the House Subcommittee on Workforce Protection Committee on Education and the Workforce, June 22, 2000.

10. Hepatitis B Risk 2-40% risk for Hepatitis B with contaminated device Unlike HIV and Hepatitis C in which there is no vaccine, Hepatitis B is preventable with vaccine Regulations requiring vaccination of health care workers has resulted in the reduction of cases from 17,000 to 400 annually Source: American Nurses Association. Nursing Facts Needlestick Injury. ANA fact sheet on Needlestick Injury. Retrieved December 31, 2004 from http://www.nursingworld.org/readroom/fsneedle.htm

11. Bloodborne Pathogen Regulations Title 29 of the Code of Federal Regulations 1910, 1030 –Universal (now Standard) Precautions –Personal Protective Equipment –Engineering Controls –Bloodborne Pathogen Exposure Control Plan

12. Needlestick Safety and Prevention Act 2000 Revised the previous Bloodborne Pathogen Standard to require: 1. The evaluation and implementation of safer needle devices 2. Documentation of non-managerial staff involvement in selection of safer devices 3. The establishment and maintenance of a sharps injuries log. U.S. Department of Labor Occupational Safety and Health Administration. 12/18/2001 Compliance Directive for Bloodborne Pathogen Standard Updated- Includes revision mandated by the Needlestick and Prevention Act.

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

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

15. Tucked into 2003 federal Medicare law Center for Medicare/Medicaid Services requirement for facilities (including governmental entity hospitals and clinics) to comply with BBP standard and that fines will be imposed for those who fail to comply

16. OSHA Directs Single Use of Blood Tube Holder Risks to health care worker and to patient Clinical studies have shown a 50-80% contamination of the blood tube holder after one usage Perry, J. and Jagger, J. Reuse of blood tube holders, redux. Preventing Occupational Exposures to Bloodborne Pathogens. Articles from Advances in Exposure Prevention, 1994-2003 Vol. 6, no.4, 2003; 230- 231. The Safety Institute, Premier Inc. 2004

17. Implementing Laws and Directives Changing from Glass: 1.Plastic Blood Tubes 2.Mylar-Wrapped Capillary Tubes with self sealing Tips that require no pressure 3.Plastic Slides Needleless systems and Safety Sharps One time use of Blood Tube Holders Dedicated glucose monitors, insulin vials and lancets

18. U.S. Sharps Injuries CDC estimates that there are 385,000 needle and other sharps-related injuries sustained by hospital-based and other healthcare personnel per year (an average of 1000 injuries per day) Source: CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program

19. Inconsistency in Reporting and Profound Underreporting May be as high as 70% in some facilities Source: DeBraun, B. A Decade of Needlestick Prevention: A California experience. Infection Control Resource, 2001

20. Texas Governmental Entity Sharps Injuries Year Number of Injuries 2001 1789 20021622 20031779 20041686

21. Type of Facility Reporting Sharps Injuries Hospital/Health Centers 71.83% Colleges/Universities21.71% City/County Services 3.62% State Facilities 1.30% Schools.77% Home Health.36% LTC.18% Source: 2004 Texas Contaminated Sharps Injuries Report

22. Job Classification With Greater Number of Sharps Injuries R.N. 23.67% MD/DO 22.18% Intern/Resident 8.66% Operating Room staff 6.94% Laboratory 6.35% LVN 6.23% 2004 Texas Contaminated Sharps Injuries Report

23. Work Areas with Greatest Number of Injuries Operating Room28.35% Patient/Resident Room19.16% Procedure Room 9.91% Emergency Dept 9.13% Laboratory 4.80% L&D/GYN 4.27% Medical/Outpatient 3.97% 2004 Texas Contaminated Sharps Injuries Report

24. Devices Related to Greatest Number of Injuries Suture Needle 22.89% Disposable Syringe 14.23% Other Syringe 10.97% Scalpel 7.71% Surgical Instruments 6.58% Winged Steel Needle 6.23% Vacuum Tube Collection 3.32% Source: 2004 Texas Contaminated Sharps Injuries Report

25. Procedure at Time of Injury Injection 18.80% Suture Skin 13.94% Draw Venous Blood 11.80% Suture Deep 9.79% Cutting 9.13% Start IV/Heparin Lock 6.67% Obtain Fluid/Tissue Sample 5.22% 2004 Texas Contaminated Sharps Injuries Report

26. Cost of Sharps Injuries Medical care ranges from $500 to $3,000 depending upon the treatment Costs are hard to quantify- Direct and indirect costs such as drug toxicity Cost of emotional trauma to employee Workers comp., burden of medical care Societal cost associated with HIV/Hepatitis Cost of any associated litigation Source: CDC Workbook

27. Screening/Testing and Implementing Safety Sharps Assess facility needs-which areas are not using safety engineered devices Collect baseline data as to employee injuries and type of sharp involved Review patient infection rates per type of device Develop/use existing team to address safety sharps issue

28. Safety Sharps Evaluation Sharps Evaluation Team 50% frontline staff Set criteria for screening and testing Use standardized scoring forms Seek devices that are rated at least acceptable [Retractable syringes are an improved technology to sliding sheath] Team decides which device will be tested

29. Sharps Evaluation Team Recommends Safety Device Yes No BD Sharps Container 5 3 Roche Safe-T-Pro Plus Lancet 8 1 BD Winged Needle 7 1 Report 2004 Clinical Testing

30. Vendor Role 1. Demonstrates device at screening workshop 2. Provides staff education 3. Supplies free devices for clinical testing 4. Serves in informational/support role if there are problems with the device 5. Has sufficient devices available to meet facility/agency needs

31. Criteria for Screening/Testing Ease of identification and handling of the device How well the product will work with other devices Can the product be used with one hand Does it work for both left and right-handed persons Is it easy to use while wearing gloves Training and Development of Innovative Control Technology Product, Trauma Foundations,San Francisco,CA Needlestick Prevention Devices ECRI,

32. Screening/Testing Criteria (cont.) Will the healthcare worker know when the safety feature is activated Is the exposed sharp covered after use Does this device cause more pain or more sticks to the patient Does this device cause more risk for patient infection Is device better than currently used device

33. Implementation of Safety Sharps Devices that receive the highest scores are recommended by the Sharps Evaluation Team for Implementation A plan for implementation includes -getting staff support -providing staff education -Budgeting for the device -Follow-up

34. Implementation Consider using established guidelines for the insertion of central lines that bundles: Aseptic technique (maximal barriers), approved skin antiseptic, type of dressing, monitoring of patient and device, type of device and adherence to approved time frames for device remaining in place CDC Guidelines

35. O.R. Work Practice Controls Include: Using instruments rather than fingers to grasp needles, retract tissue and load/unload needles and scalpels Giving verbal announcements when passing sharps Avoid hand-to-hand passage of sharps Use alternative cutting methods blunt electrocautery, laser Substitute endoscopic surgery when possible Use round-tipped blades Source: CDC Workbook

36. Follow-up 1. Is the device used-determine how to manage staff resistance 2. Are there fewer injuries-if no, why not 3. Are there more infections-look for the root cause 4. Consider work processes, staffing, worksite climate, device

37. Healthcare Worker Role The employer can provide safer devices, but it is up to the staff person to: 1. Know which devices are at higher risk 2. Know how to reduce the risk 3. Know what to do in processes that will always have risks Source: Perry, Jane et al. How to avoid needlesticks. RNWEB 2004

38. Effects of Implementing Safety Engineered Devices Comparison study showed: Mean annual InjuryBefore After Incidence per 1000 FTE 34.08 14.25 (P<.0001) Source: Sohn, S. et al. Effects of implementing safety-engineered devices on percutaneous injury epidemiology. Infection Control Hospital Epidemiology.2004 Jul;25(7):536-42.

39. Review of Information Where we are in Bloodborne Pathogen Statistics Current federal and state BBP regulations Sharps Injuries Among Texas Govt. entities Safety Engineered Sharps Device Use