Implementation of the Needlestick Safety and Prevention Act in long-term care facilities

 The long-term care arena has a long history of facing and mastering difficult challenges. In recent years, these have included implementing the Omnibus Budget Reconciliation Act (OBRA), proactively planning for and adapting to the Prospective Payment System (PPS), maintaining readiness for inspections by the Occupational Safety and Health Administration (OSHA),1 and, more recently, implementing the Needlestick Safety and Prevention Act.

One might think that implementing a sharps-injury prevention program in long-term care would be relatively easy, since far fewer sharps are used in long-term care than in acute-care facilities. However, all components of the Needlestick Safety and Prevention Act apply to long-term care and had to be implemented with great detail. An additional challenge in many facilities is the fact that the infection-control professional (ICP), who frequently leads the implementation efforts for sharps safety, often has multiple job functions in addition to infection control. Coupled with a national nursing shortage and staffing issues throughout the long-term care industry, this makes it often difficult to provide patient care and to focus time on new initiatives and regulations. The need to implement a program such as sharps safety often requires scheduling changes and, sometimes, re-assignment of job functions within the system.

Although the challenges in long-term care facilities might be great, this article shows how Life Care Centers of America successfully implemented the Needlestick Safety and Prevention Act in 215 nursing homes.

Nursing and personal-care facilities have one of the highest rates of injury and illness among industries for which nationwide lost-workday injury and illness (LWDII) rates were calculated for calendar year 2000.2 According to the Bureau of Labor Statistics, in that year nursing and personal-care facilities experienced an average LWDII rate of 7.9, despite the availability of feasible controls to address hazards within this industry. This is more than double the LWDII rate of 3.0 for private industry as a whole.

Data on needlestick and other sharps injuries specific to long-term care facilities is not readily available for review. However, the National Institute for Occupational Safety and Health (NIOSH) has published in “Safer Medical Device Implementation in Health Care Facilities: Sharing Lessons Learned” a couple of years of sharps injury data for one 500-bed long-term care facility accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).3 Injury rates are not given, but the type of injury, device used, and specific situations are (table 1).

During October 2000 through September 2001, OSHA performed 190 inspections of skilled-nursing facilities and gave 487 citations relating to bloodborne pathogens. The cumulative monetary penalties were nearly $310,923. In comparison, during the same period there were 50 inspections of hospitals, with 139 citations and penalties of $96,175.4

The Needlestick Safety and Prevention Act became law in the United States on November 6, 2000. It authorized the Occupational Safety and Health Administration to require the use of sharps devices with engineered safety features. The effective date of the legislation was April 18, 2001.5 The use of devices with engineered sharps injury protection was already required by a November, 1999 OSHA compliance directive regarding exposure to bloodborne pathogens.6 In addition, the Needlestick Safety and Prevention Act required the following:

• exposure control plans that reflect how employers implement new developments in sharps-injury prevention technology and documentation of annual review
  
• definition of engineering controls to include devices with engineered sharps-injury protection as well as needleless intravenous administration systems
  
• input by front-line, non-managerial healthcare workers at least annually into identification, evaluation, and selection of devices and other controls, with documentation in the exposure control plan
  
• a log that documents all injuries from contaminated sharps that penetrate the skin
  

OSHA also requires that the safety devices chosen be appropriate, commercially available in sufficient quantity, and effective.

In November, 1999 NIOSH made recommendations to employers on preventing needlestick injuries in health care settings.7 NIOSH summarized desirable characteristics of safety devices:

• The device is needleless.
  
• The safety feature is an integral part of the device.
  
• The device preferably works passively (i.e., it requires no activation by the user). If user activation is necessary, the safety feature can be engaged with a single-handed technique and allows the worker’s hands to remain behind the exposed sharp.
  
• The user can easily tell whether the safety feature is activated.
  
• The safety feature cannot be deactivated and remains protective through disposal.
  
• The device performs reliably.
  
• The device is easy to use and practical.
  
• The device is safe and effective for patient care.
  

NIOSH further stated that needlestick injury reduction can best be accomplished when improved engineering controls are incorporated into a comprehensive program involving workers that includes the following directives:

• Analyze needlestick and other sharps-related injuries in your workplace to identify hazards and injury trends.
  
• Set priorities and prevention strategies by examining local and national information about risk factors for needlestick injuries and successful intervention efforts.
  
• Ensure that healthcare workers are properly trained in the safe use and disposal of needles.
• Modify work practices that pose a needlestick-injury hazard to make them safer.
  
• Promote safety awareness in the work environment.
  
• Establish procedures for and encourage the reporting and timely follow-up of all needlestick- and other sharps-related injuries.
  
• Evaluate the effectiveness of prevention efforts and provide feedback on performance.
  Although these recommendations preceded the Needlestick Safety and Prevention Act, the steps have been used by many healthcare facilities, and they helped to format the framework for preparation, implementation, and evaluation described below.
  

Life Care Centers of America (LCCA) is a large for-profit long-term care company based in Cleveland, Tennessee. Founded in 1976, Life Care Centers of America has grown to be one of the largest healthcare management companies in the USA, operating more than 260 nursing, subacute-care, rehabilitation, assisted-living, retirement, home-health, and Alzheimer-disease centers in 28 states.

LCCA implemented the Needlestick Safety and Prevention Act in each of their 215 long-term care facilities across the nation. In the preparatory phase, their standardization committee, consisting of frontline representatives as well as corporate support associates, assessed the types of sharps being used in the facilities and obtained devices from four companies that manufacture and/or distribute sharps with engineered sharps-safety protection. Needleless intravenous administration systems were already in place. The devices that lacked engineered sharps-safety protection included syringes, lancets, phlebotomy needle holders, winged blood-collection sets, and scalpels (used mainly for wound debridement and packaged in a wound debridement kit). In addition, the committee chose to re-evaluate the sharps containers.

Front-line nursing associates conducted field evaluations for thirty days. The initial evaluation criteria for each device included safety, efficacy of the active or passive activation feature, performance, availability, reliability, effects on residents’ care, and acceptance by associates. Three months later, front-line nursing associates and the standardization committee reviewed the evaluations. They selected Kendall products because of their safety features. Some important features include:

• The Monoject safety syringe has a very secure safety shield that covers the needle completely during transport and after use. The syringe also allows for intermittent drug delivery, because the transport position allows the nurse to cover the needle with the shield instead of recapping it during titration, keeping the fingers away from the needle. The Monoject syringe allows activation with fluid still in the barrel.
  
• The phlebotomy needle holders have back-in protection as a double safety feature. In addition, they prevent splatter with one-hand activation.
  
• The winged collection set is a unique self-sheathing system with one-hand activation of the safety mechanism. The wings are textured for secure handling.
  

Facility executive directors were notified of the product selections. Directions were given for implementation including completing an inventory of current supplies and blocking further orders for the non-safety-engineered sharps.

One month later a planning meeting was held with regional clinical directors and representatives from Kendall. Plans were finalized to deliver products to each LCCA facility and to train all associates in their use.

Six months after the preparatory phase began, training was completed. LCCA initiated use of the safety-engineered devices. Regional, divisional, and clinical directors and vendors conducted additional follow-up and training as needed.

Concurrent with the implementation phase, the Bloodborne Pathogens Exposure-Control Plan, was revised as required by the legislation, to reflect the annual evaluation of the safety-engineered devices by non-managerial associates and the use of the sharps-injury log. OSHA requires that the log include injuries from contaminated sharps that penetrate the skin. It must contain the type and brand of device involved; the location of the incident, including the department or work area where the incident occurred; a description of how the incident occurred; and the body part affected. This log does not replace the OSHA work-related injury logs and forms OSHA 300 and 301. See figure 1 for the sharps-injury log used by Life Care Centers of America. LLCA also chose to use their own sharps-injury report form to facilitate analysis of the cause of each injury.

The preparatory phase included planning for initial and on-going evaluation. LCCA standardized evaluation forms for all facilities, with a form for each device in use (see figure 2). Individual users of each device completed these forms. Meetings were held in each facility with non-managerial associates to review the evaluation forms and to discuss issues relating to the devices in use. The results of the individual device evaluations were then summarized on the “Safer Medical Device Selection Summary” form (see figure 3). Summaries of the meetings and the evaluations were sent to the LCCA standardization committee for review. The standardization committee determined six areas of concern:

• associates’ lack of knowledge of proper technique in using the devices
  
• occasional lack of safety engineering in devices supplied by the contract laboratory
  
• overfilling of sharps containers
  
• residents’ complaints of pain from the new lancets
  
• ability of residents to get their hands into the sharps containers
  
• residents offended to see used needles and syringes in the sharps containers
  

A vendor representative met with the standardization committee to serve as a resource and to answer questions. The committee chose to continue using the devices that had previously been chosen with the exception of the lancet, which was causing undue pain for the residents. The facilities’ executive directors and directors of nursing were given the following recommendations:

• training and competency assessments of associates on use and disposal of safetyengineered sharps devices during orientation
  
• annual inservice training with repeat competency assessments
  
• random compliance rounds with appropriate follow-up training
  
• repeat facility training by vendor representative if needed
  
• notification of contract laboratory to deliver safety devices; otherwise, facility stock to be used
• replace lancet with one having re-designed gauge and depth
  
• secure the full sharps containers in a locked cabinet until pick-up by the biomedical waste company
  

LCCA also announced that it would continue evaluating sharps containers that use hands-out technology with the lid stopping in the full position when it reaches maximum capacity.
The facilities will maintain their original evaluations, summaries, and LCCA standardization committee recommendations, including subsequent action that is taken. Each May the front-line associates will evaluate the effectiveness of all safer medical devices. The project will be directed, as it was this year, by clinical services and the standardization committee.

In general, LCCA’s implementation of the Needlestick Safety and Prevention Act was accomplished in an organized and effective manner. The challenge of implementing new legislation during a nationwide nursing shortage and a general long-term care staffing shortage was difficult but?typical of many healthcare professionals?the staff came through even though the device trials and evaluations added to their workloads.

The greatest challenge in implementing any new process within a large corporate structure is communication. LCCA planned for an effective communication process in the early stages of this project. However, the company did not receive device evaluations from all of the 215 facilities during the established time frame. Therefore, one lesson learned is that future projects of this magnitude must be more decentralized, with divisional clinical directors being responsible for making sure the evaluations are done, gathering the summaries, and providing them to the standardization committee.

Assistance from vendor-company representatives was very helpful in presenting the products to the LCCA standardization committee, providing products to use in trials, providing sample product-evaluation forms, and educating workers.

At a corporate level, in addition to future oversight of the annual evaluations of safer medical devices, LCCA will closely monitor the tracking and trending of sharps injuries.
Over-all, cooperation from the facilities and the staff was excellent even with very challenging and demanding schedules being further taxed by the scope of this project.