Risk Control Measures
A long standing practice for controlling hazards in occupational health has been to employ the “occupational hygiene” model, which describes control measures for any hazard as being directed either at the source of the hazard, along the path to the workers, or at the workers themselves. The model holds that the most effective strategy to control any hazard is at the source of the hazard itself, or where that is not possible as close as possible to the source of the hazard. Where a control at the source or along the path between the hazard and the worker is not possible, controlling a hazard at the worker themselves may be the only alternative. In essence the model is a hierarchy of controls and is known as the “occupational hygiene hierarchy” of controls. Use of the hierarchy of controls for any hazard is considered a best practice. The hierarchy of controls can be described as risk control measures in descending order of effectiveness. These risk control measures would include such measures as; (1) elimination of a hazard; (2) engineering controls; (3) administrative controls; (4) work practices, and; (5) personal protective equipment.
With respect to medical sharps and sharps injuries, the hierarchy of controls may be described in the following manner in terms of most effective to least effective:
Removing the source of potential exposure by eliminating the sharp device altogether is the most effective risk control measure. Examples include the use of needle-less IV systems and replacing wound suturing with adhesives.
- Engineering Controls
Where a sharp cannot be eliminated it may be controlled using engineering and safety engineered features. This would be considered a less effective solution as it allows the hazard (the sharp object) to exist, but applies controls at the sharp object itself. There is extensive data on the efficacy of safety engineered medical sharps.
- Administrative Controls
Administrative controls are the next most effective risk control measure. They include an effective occupational health program with clearly defined objectives, adequate staffing, relevant policies and procedures, including those to ensure adequate surveillance and analysis of injuries and potential exposure to infection and infection control measures, including vaccination of health care workers.
- Work Practices
Safe work practices includes such things as a strict adherence to prohibitions on the re-capping of needles, requiring that sharps are disposed of using an appropriate sharps disposal container, ensuring that sharps containers are not overfilled and that they are handled and disposed of properly. Safe work practices will also extend to issues such as requiring that personal protective equipment is removed before leaving the work area, and that there is appropriate interactive training of all staff who are at risk from blood and body fluid exposures.
- Personal Protective Equipment
Personal protective equipment is not very effective against the prevention of a sharps related injury. Gloves, as an example, provide very little defense against puncture from a sharp object. Personal protective equipment such as gloves, masks, gowns and facial shields which are used to provide a barrier against exposure to blood borne pathogens through splash and spray do provide some protection to workers and are a necessary part of routine infection control practices. However, it should be understood that although appropriate personal protective equipment lowers the risk of exposure, it is still considered to be a less desirable control than other measures as an overall control strategy. The Public Health Agency of Canada refers to this in its guideline Prevention and Control of Occupational Infections, where it states that " ... engineering controls decrease or eliminate the hazard, whereas the use of personal protective equipment only provides a barrier between the health care worker and the hazard." (PHAC, 2002)
Use of Safety Engineered Medical Sharps
Research has shown that the use of safety engineered medical sharps can reduce the incidents of sharps-related injury within a health care setting. CDC reported studies have shown a reduction of up to 76% of reported injuries in some cases where phlebotomists have used SEMS (CDC, 1997). NIOSH has also reported on studies that have identified injury reductions of 62% to 88% (NIOSH, 1999). Furthermore, analysis of EPINet data collected in the US shows a clear decline in the number of sharps injuries after implementation and use of SEMS (Perry, Parker and Jagger, 2003).
Studies have demonstrated general acceptance of safety features. Factors that will influence staff use of SEMS include such things as:
- Perceived risk of infection
- Design of the device
- Training in the use of the device
- Length of time to become adept
- Ease of use
- Required changes in technique
- Previous experience with safety devices
Rejection of new devices is associated with a lack of training or support for change in the clinical environment (OSHA, 1997).
The use of SEMS on their own is not sufficient. A comprehensive approach to BBF exposure prevention is required, with safety devices being part of the program. Without appropriate support and education, SEMS may not be used, or may be used incorrectly. One CDC study found that 61% of the injuries with sharps that had a safety feature occurred prior to activation of the safety feature. This finding underscores both the need for consistent education and support for the devices and, where possible, the use of devices that are “passive”–that is, they do not require any additional action by the user.
When implementing a sharp injury prevention program, NIOSH offers the following advice to employers:
- Analyze sharps injuries and identify hazards and trends
- Set priorities and strategies for prevention by examining local and broader risk factors
- Ensure proper training
- Modify work practices that pose a needle-stick hazard
- Promote safety awareness
- Establish procedures and encourage reporting of all injuries and incidents
- Evaluate the effectiveness of all prevention activities
The variety of SEMS available on the market is extensive, and new models and features are being introduced all the time. It is important for any organization making the transition to safer products to thoroughly investigate and conduct trials of new devices within the context of a comprehensive program. Applying the occupational hygiene model to the use of sharps provides a good foundation. In the model, the best way to protect staff is to eliminate the “sharp” object altogether. This approach is possible and has been achieved in many hospitals with the use of needle-less IV access systems.
Where a sharp cannot be eliminated, an engineered solution would be the next most desirable course of action. Sharps with engineered safety features are classed either as passive or active devices.
- Passive: the safety feature of the device is engaged automatically or without any additional action required on the part of the care provider
- Active: the safety feature requires an additional action on the part of the care provider
From a safety perspective, a passive device is more desirable. Where engineered solutions are not possible, work practice controls are the next line of defense, followed by personal protective equipment (PPE).
The desirable features of a safety engineered medical sharp have been described by the National Institute for Occupational Safety and Health (NIOSH, 1999). (See Appendix I.)
The WSIB average cost for no-lost-time claims related to needle sticks is approximately $91. The average cost for lost-time claims is approximately $2,357. The total claim count of needle-stick injuries, excluding all other sharps injuries and blood and body fluid exposures in the health care sector was $132,000 in 2004. Claim counts are rising fast, from 700 in 1999 to almost 1,400 in 2003. These figures do not include all of the claims made in other sectors, including those health care settings that are part of the WSIB Schedule 2 workplaces, (employers that self-insure). Within this context, costs will go up.