1. Sharps Injury Surveillance and Prevention in Massachusetts
Champions
Collaborative effort
Parallel efforts
Integration
Extension beyond hospitals
Angela K. Laramie, MPH
Massachusetts Sharps Injury Surveillance System
Occupational Health Surveillance Program
MNA
June 2007

2. Background Risk of being exposed to HBV, HCV, and HIV
Risk of infection for:
HBV 6% to 30%
(for those not immune to HBV)
HCV % (range 0% to 7%)
HIV %
Estimates of prevalence among general population:
HIV
HBV
HCV 1-2%
These figures undescore the need for Hep B vaccines to be offered at no charge, as required by the Federal Bloodborne Pathogens Standard, to all employees in health care who may be exposed to potentially infectious blood and body fluids.

3. Costs of sharps injuries
Direct costs
includes cost of EH personnel, lab tests, HBV immune globulin, HBV vaccine
ranges from $110 - $1,232
Includes medical care after seroconversion
ranges from $32,000 - $500,000
Indirect costs - difficult to quantify

4. Sharper images: Despite needlestick law, nonsafe sharps practices still go unchecked By Ed Frauenheim February 12, 2001 Nurse Week Photo: Courtesy of the White House

5. Timeline of Regulations
December 1998
Legislation filed by Massachusetts Nurses Association
August 2000
An Act Relative to Needlestick Injury Prevention (Massachusetts)
November 2000
Needlestick Safety and Prevention Act (Federal)
January 2001
OSHA revised Bloodborne pathogen standard
April 2001
MDPH regulations (included in hospital licensure regulations)

6. States with sharps legislation:
1998
2000
Ohio
California
West Virginia
Massachusetts
Minnesota
New York
1999
Maine
Tennessee
Georgia
2001
Maryland
Iowa
Arkansas
Texas
New Hampshire
Missouri
New Jersey
Alaska
Rhode Island
Connecticut
Pennsylvania
As of June 2002
Oklahoma

7. MDPH Sharps Injury Prevention Regulations 105 CMR 130.1001 et seq.
Requires hospitals to:
Incorporate the use of safe needle / sharps devices into engineering and work practice controls
Maintain a written exposure control plan
with procedures for selecting safe devices
Every hospital shall ensure the provision of services to individuals through the use of safe needle devices and other technology that minimizes the risk of injury to HCW from needles and sharps.
ECP shall follow requirements of OSHA standard
WAIVER Purchasing / value analysis committee to act as gate keeper

8. MDPH Sharps Injury Prevention Regulations 105 CMR 130.1001 et seq.
Requires hospitals to:
Maintain a Sharps Injury Log
Use data for continuous quality improvement
Report to MPDH annually (Annual Summary)
Requires MDPH to:
Establish an Advisory Committee
Develop a list of needleless systems
Health Care Worker means:
all workers employed in the hospital,
working within the hospital but employed by other agencies,
those providing patient care services without pay such as students, or
providers who are delivering care but receiving compensation from sources other than the hospital.
It is important to note that public sector healthcare workers were covered under a provision of the Medicare Modernization Act in All Medicare participating hospitals must now comply with 29CFR , OSHA’s Bloodborne Pathogens Standard.

9. MDPH Sharps Injury Prevention Advisory Committee
Occupational Health Surveillance
Bureau of Communicable Disease Control
Division of Health Care Quality
Mass Nurses Assoc.
Mass Hospital Assoc.
Mass Medical Society
UMass: Sustainable Hospitals Project
NECOEM
Consumer Advocate
Committee pulled together to address issue - included 20+ people – hospitals, unions, DPH – SLI, HCQ, HQM, OHSP.
Sub committees of education, surveillance and safety devices
Final legislation required the establishment of a committee and prescribed which entities would be represented on the committee

10. Objectives of the Sharps Injury Surveillance System
Document magnitude of the problem and trends in sharps injuries among hospital workers overtime
Identify departments, occupations, procedures, and hospitals where intervention is needed
Identify devices associated with sharps injuries
Facilitate sharing information among hospitals about successful programs and practices
Overarching goal: to prevent sharps injuries
This is achieved through…
This is not a disease surveillance system, but rather an exposure surveillance system

11. Methods
Population under surveillance: All health care workers in Massachusetts hospitals (acute and non-acute care) licensed by MDPH
Reportable exposure incident: BBP exposure that is the result of events that pierce the skin or mucous membranes
Reporting period: January 1 – December 31
Coding structure is based on the CDC NaSH system

13. Sharps Injuries among Massachusetts Hospital Workers, 2002 -2004
2003
2004
# of hospitals
101 99
% compliance
100%
# of injuries reported
3,413
3,327
3,276
Range of # of injuries reported
0 – 431
1-317
% injuries in acute care hospitals
97%
% injuries in teaching hospitals
40%
58%
59%
Strengths:
Full participation by hospitals → amount of data in system
Addresses multiple regulatory requirements
Used by hospitals for continuous quality improvement
Provides a mechanism for sharing information among hospitals
Increase in % of injuries in teaching hospitals is due to the increase in the number of teaching hospitals.

14. Sharps Injuries among Hospital Workers by Occupation, Massachusetts, 2002-2004, N=10,016

15. Sharps Injuries among Massachusetts Hospital Workers, 2002-2004 top 4 occupations
Percentage of injuries

16. Sharps Injuries among Massachusetts Hospital Workers, 2002-2004 top 4 occupations
# of injuries

17. Sharps Injuries among Hospital Workers by Department, Massachusetts, 2002-2004, N=10,016
Robots in the OR – moved from minimally invasive surgeries (2D, laparoscopic + camera) to robots (3D, 7 degrees of freedom)
Only 1 FDA approved system – da Vinci
Surgeon sits at a console and manipulates robot with controls

18. Sharps Injuries among Massachusetts Hospital Workers, 2002-2004 top 4 departments
Percentage of injuries
Better reporting in the OR

19. Sharps Injuries among Hospital Workers by Procedure or Purpose for which Device was Used, Massachusetts, , N=10,016
Injection:
Anesthesiology
Making the incision:
Scalpel use
Line procedures:
PICC lines – ultrasound used for placement

20. Sharps Injuries among Hospital Workers by Device, Massachusetts, 2002-2004, N=10,016
Hollow bore needles
57%
ACS:
Cuts and needlestick occur in 1-15% of all surgeries
59% of all needlestick injuries occur while suturing fascia
ACS supports univeral adoption of blunt suture needles as the first choice for suturing fascia
Alternative methods of closure:
Glues
Staples
Surgical zippers (laparotomy)
clozex

21. Sharps Injuries among Hospital Workers by Conventional Devices, Massachusetts, 2002-2004, N=10,016
Unknown – sometimes employees don’t know
CDC data demonstrates:
38% of injuries occur during use
42% of injuries occur after use and
before disposal

22. Sharps Injuries among Massachusetts Hospital Workers, 2002-2004 % safety devices
Percentage of injuries

23. Sharps Injuries among Hospital Workers by Device Involved in the Injury, Massachusetts, , N=10,016
Hypodermic needles:
Multiple use by anesthesiologists
Solutions: use device with sliding sheath, partially activate so that it covers needle but can be pulled back to administer meds
Draw up several syringes with smaller doses, rather than use one syringe for multi-dosing
One hospital is working with pharmacy to have medication in unit doses packaged in prefilled syringes with safety features
Suture needles:
One study: 59% of suture needles injuries caused by suturing facia or muscle – BLUNT suture needles would be appropriate here
Alternative methods of closure:
Glue
Staples
Zippers

24. Sharps Injuries among Hospital Workers by Device - Standard v Safety, Massachusetts, (excluding unknown)
Point – proxy of # of safety devices purchased / used
Hypodermic
Butterfly
Vacuum tube
Scalpel

25. Sharps Injuries among Hospital Workers by Department where Injury Occurred, Massachusetts, , N=10,016

26. Sharps Injuries among Hospital Workers with Hypodermic Needles by Procedure - Standard v Safety Device, Massachusetts, , n=2,984

27. Sharps Injuries among Hospital Workers with Hypodermic Needles by Procedure – Conventional v Safety Device, Massachusetts, , n=942

28. Sharps Injuries among Hospital Workers in the OR by Device, Massachusetts, 2002, n=935
Hollow bore needles
23%

29. Sharps Injuries among Hospital Workers in the OR by Device: Conventional v. Safety, Massachusetts, 2002, n=935
Hypodermic needles:
Multiple use by anesthesiologists
Solutions: use device with sliding sheath, partially activate so that it covers needle but can be pulled back to administer meds
Draw up several syringes with smaller doses, rather than use one syringe for multi-dosing
One hospital is working with pharmacy to have medication in unit doses packaged in prefilled syringes with safety features
Suture needles:
One study: 59% of suture needles injuries caused by suturing facia or muscle – BLUNT suture needles would be appropriate here
Alternative methods of closure:
Glue
Staples
Zippers

30. Strengths of Massachusetts Program
Census of hospitals
Not biased by voluntary reporting
Concordance with federal requirements
Used by hospitals for continuous quality improvement
Provides a mechanism for sharing information among hospitals
Provides a model to be used in other settings
Full participation by hospitals → amount of data in system
Addresses multiple regulatory requirements

32. Data Limitations
Rate of underreporting is unknown and likely varies by hospital/occupation
Underestimates magnitude
Limits comparison among hospitals
Limitations of denominator data
Statewide data on specific devices is difficult to interpret without market share information
DENOMINATORS:
Licensed beds
Occupied beds
FTE
# of procedures
# of patients

33. # of sharps injuries # of devices w/ safety features purchased
Response rate for device
evaluations
Timeliness of PEM
Level of under reporting

34. Conclusions Need to look beyond summary data
Need better information about under-reporting
Conversions:
conventional → safety
→ first generation ↔ second…fourth generation
Successes may be missed if only summary numbers are considered
Without knowing the extent of under-reporting, injury data alone may mask success of addressing particular hazards
MAIN POINT: need to look at things other than # of total injuries

35. Conclusions Patterns are similar to those found in NaSH and EPINet
Many standard devices are still in use; e.g. hypodermic needles
Approximately half of injuries occur after use of the device; e.g. disposal issues and use of safety features
Rate of participation may be driven by the ability to comply with multiple regulations at one time

36. Prevention Elimination Substitution · suturing  glues
· injection with needles  alternative delivery of medications
Engineering controls
· IV systems  needleless IV
· conventional needles  SESIPs
(retractable, blunting, shielding, plastic)
Dissemination of reports
Annual meetings with hospitals
Structured site visits
Technical assistance
Conference calls
Under-reporting survey
Pilot of CDC Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program
Sharps injuries in the home care setting

37. Prevention Administrative controls · neutral zones in OR
· placement of sharps disposal containers
· purchasing policies
· reporting procedures
Personal Protective Equipment
· gloves, mask, gowns, goggles

38. Progress by Hospitals:
Written inventory of devices
Increased conversion to safety devices
Review of safety devices
Committee to look at sharps related injuries
Committee to look at new devices
Involvement of staff in decision making
Centralized purchasing process
Improved post exposure management
Use of data in decision making
Reporting of near misses
Convene a multidisciplinary team
Implement administrative controls (purchasing)
Know what devices are being used in the facility
Encourage reporting of injuries / exposures
Streamline post-exposure management

39. Acknowledgements:
Phil Adamo, Evie Bain, Helene Bednarsh, Al DeMaria, Karen Daley, Tish Davis, Natalia Firsova, Catherine Galligan, Anuj Goel, Liz O’Connor, Gail Palmeri, Laurie Robert, Margaret Quinn, and Jim Ryan
This presentation is dedicated to Dr. James Ryan, for his passionate work to protect the health and safety of workers, particularly those in the healthcare field.

40. Sharps Injury Surveillance and Prevention
Massachusetts Department of Public Health Occupational Health Surveillance Program
Angela Laramie, MPH
Sharps Injury Surveillance and Prevention