- Email: [email protected]
Reducing Sharps Injuries Among Health Care Workers: A Sharps Container Quality Improvement Project
THE JOINT COMMISSION Conversion from a “straight-drop” to a “letter-box” sharps container enabled the medical center to the reduce the rate of needlestick injuries by two-thirds, at a cost savings of more than $62,000 a year.
Reducing Sharps Injuries Among Health Care Workers: A Sharps Container Quality Improvement Project IRENE B. HATCHER, MSN, RNC
S
harps injuries directly related to disposal in a safety container may seem like an oxymoron, but in 1997 Vanderbilt University Medical Center (VUMC; Nashville, Tenn) noticed a high incidence of injuries directly related to disposal. We undertook an analysis of the problem, implemented a change in sharps container style, and realized a significant reduction in needlestick injuries directly related to the disposal process. But the transition was not easy. What looked like a simple process proved to be very complex. This article provides a review of our journey.
Analyzing the Problem The VUMC administration has been committed to providing a safe environment for the staff and recognized the importance of implementing safety products as a way to reduce needlestick injuries. We at VUMC were early adopters of a needleless IV (intravenous) system in 1995. We began using the earliest version of “safety needles” and have continued to introduce new Irene B. Hatcher, MSN, RNC, is Chair of the Medical Cen-
ter Value Analysis Committee (VAC) and Coordinator of Case Management, Office of Case Management, Vanderbilt University Medical Center, Nashville, Tennessee. The author extends special thanks to Patricia Kinman, MSN, RN, CS, NP, Clinical Manager, Vanderbilt Occupational Health Copyright © 2002 by the Joint Commission on Accreditation of Healthcare Organizations
410
safety products as they have become available. We continuously reevaluate the products that are in use. Product selection at VUMC is made by its Value Analysis Committee (VAC), a multidisciplinary group whose purpose is to provide a systematic approach to the evaluation, selection, and standardization of patient care supplies and equipment, current and proposed, to ensure that the hospital is receiving the optimum benefit from all money spent. It also provides ongoing direction and education, and it creates policies for patient care supply and equipment utilization. Committee members consist of representatives from each of the clinical patient care centers divisions (for example, surgery, medicine, emergency, children’s) and from areas of special expertise such as biomedical engineering, IV therapy, infection control, and radiology. This committee composition ensures a great deal of clinical input in the selection of safety products. Although VUMC has used this model since 1994, many institutions have only begun to incorporate clinClinic, and Daniel W. Byrne, MS, General Clinical Research Center, Vanderbilt University Medical Center. Please address requests for reprints to Irene B. Hatcher, MSN, RNC, Office of Case Management, Vanderbilt University Medical Center A 1202 MCN, 1161 21st Ave S, Nashville, TN 37232-2415; phone 615/343/7944; fax 615/343-4866; e-mail [email protected].
J U LY 2002 J O U R N A L
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
JOURNAL
ON
QUALITY IMPROVEMENT
Article-at-a-Glance Background: Many needlestick injuries at Vanderbilt University Medical Center were found to be related to the method of disposal in sharps containers. The “straight-drop” system allowed staff to stuff more needles into a full box, resulting in needlestick injuries. This was also a common problem elsewhere, as reflected in the literature. Analyzing the problem: A multidisciplinary committee reviewed other sharps containers, piloted one, found problems, and then piloted and selected another. Implementation was complex and difficult, but focus was kept on the goal of decreased needlestick injuries. Staff identified other problems, which were
ical input because of recent Occupational Safety and Health Administration (OSHA; Washington, DC) regulations. Because the supply chain is so important in making products available, representatives from purchasing, inventory, and central supply/processing also are on the committee, as is a physician consultant. The problem, as the infection control coordinator advised other VAC members, was that many needlestick injuries were directly related to disposal into the sharps containers. We used the “straight-drop” system, which allowed staff to stuff more needles into a full box, resulting in needlestick injuries. Our experience was not unusual. For example, a report from the Exposure Prevention Information Network (EPINet™; Charlottesville, Va), a standardized system for tracking occupational blood exposures, stated that overfilled containers played a major role in these injuries.1 A literature review of the problem revealed that “as many as onethird of needlestick injuries happen during disposal of sharps. These injuries typically occur because of inappropriate placement or poor design of sharps containers and overfilling of containers.”2(p 78) A 1996 EPINet report showed that 16% of the cases of needlestick injuries occurred in introducing the sharps into disposal containers.3 A 1997 EPINet review of data from 55 hospitals showed that 15% of injuries were due to disposal4; at VUMC the proportion was 15.3% (see Figure 1, p 412) before we began to address the problem.
Addressing the Problem The VAC had tried several strategies in the previous months to address the problem of disposal-related
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taken to the manufacturer of the sharps container selected and resulted in product design changes. Results: Several months after implementation, data analysis showed that the needlestick injury rate was reduced by two-thirds, a statistically significant change (p = 0.002). Despite the increased cost of the sharps container, savings of prevented needlestick injuries represented a total cost savings to the medical center of more than $62,000 a year. Discussion: This experience is an example of real-life implementation—and the problems institutions may have to overcome before success can be realized.
needlestick injuries. We had changed our sharps container from an opaque version to a translucent one, so that staff could see when the box was almost full. (With the opaque box, staff did not know the box needed to be emptied until it was completely full.) We worked with housekeeping on the importance of changing the boxes in a timely manner. None of these efforts made a difference, so we then used the Plan-Do-Study-Act (PDSA)5 model for quality improvement. Using the PDSA Model for Quality Improvement Plan: We reviewed other available sharps containers, which were then presented to the VAC. The VAC approved the “letter-drop” style system for piloting on selected units. VAC pilots products on areas of high use, high risk, or special expertise with products. In this case, we conducted the 2-week pilot studies in the cancer clinic, pediatric clinic, laboratories, emergency room, pediatric intensive care unit (ICU), and surgical ICUs. The pilot results were favorable, so medical center–wide implementation was planned. About a week before the implementation date, however, several VAC members attended a meeting on products with representatives from other hospitals. One of the hospitals reported serious complaints about the sharps container that we were about to use. Reportedly, if the box was closed too quickly, sometimes the sharps came back out like projectiles, causing injury. The reports were verified by a VAC member who had had that projectile experience using our chosen brand of sharps container at another institution. VAC
7
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
411
THE JOINT COMMISSION
Percentage
considered the reported problems, Disposal Injuries as a Percentage and after reevaluation, approved a of Total Needlestick Injuries pilot study on the same units of a 33.0% similarly designed box but made by a 35.0% different manufacturer. This second 30.0% 25.0% pilot was also successful. National 20.0% Do: We implemented the second 15% 15.3% 55 hospitals 15.0% type of “letter-drop” sharps containers VUMC 10.0% that we tested throughout VUMC. 5.9% VUMC 5.0% Many pieces of the implementation 0.0% plan needed to be synchronized. For Nursing EPINet 1/97– 3/99– ’99 ’97 12/98 8/00 example, new mounting brackets for Data Source and Period the sharps containers had to be installed before the boxes could be Figure 1. Vanderbilt University Medical Center (VUMC)’s annual rate of disposal injuries delivered to the units, and staff train- was reduced by two-thirds after the implementation of the new sharps container system in ing had to be complete before the January 1999. Source of data for EPINet™ from Jagger J, Bentley M: A sticky issue: Do boxes could be used. A major problem sharps containers protect health care workers? Materials Management Aug 1996, pp 36–38. occurred when plant operations did not realize the importance of its part in the overall drop to letter-drop containers. These hospitals scheme and had added another job as higher priority. reported similar initial acceptance problems but indiThis left some units with new sharps containers deliv- cated that sharps container–related needlestick ered and no brackets to put them in. Because we had a injuries did dramatically decrease at their institutions. “total swap out” type of implementation, the old boxes We were able to brave these implementation issues by were no longer available. focusing on our goal of reducing the incidence of needlestick injuries during the disposal process. Even Study: Soon after implementation of the new boxes, complaints came in on a product hotline to the though staff may not have liked the new sharps conpurchasing department; staff also reported problems tainers as well as the old ones, if we could reduce needlestick injuries, the conversion would be worth to VAC members: ■ The weight counterbalance in the containers did some initial dissatisfaction as staff accustomed themselves to the new boxes. not drop light-weight sharps; ■ The opening for sharps was too small if one had to We then repeated the PDSA cycle: ■ Plan: We evaluated the new design and the effect of insert multiple sharps, as in code situations; and ■ Bloody objects contaminated the “shelf ” (the area the change on injuries. ■ Do: As soon as the redesigned containers became where sharps lay before dropping into the container). Overall, staff were not very happy with the new available commercially, we implemented them on sharps containers. VUMC units. ■ Study: We conducted a staff satisfaction survey and Act: On the VAC’s recommendation, the purchasing department reported the complaints to the sharps monitored needlestick injuries related to disposal. container manufacturer. Although customers frequently ■ Act: We decided to continue to use the redesigned do not take this step, thinking their efforts would be sharps containers. futile, this particular company was very receptive. Within approximately 3 months, the company Results redesigned the sharps container, adjusting the counter- Sharps injuries are categorized by our occupational weight to empty light objects and enlarging the opening. health staff in terms of the activity being performed at the time of the injury and the product being used. These staff then attempt to determine if the injury was Repeating the PDSA Cycle The infection control coordinator consulted avoidable or unavoidable. Categorizing the injuries as other hospitals that had also converted from straight- those “that could have been prevented if the sharps
412
J U LY 2002 J O U R N A L
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
JOURNAL
ON
QUALITY IMPROVEMENT
container had been used appropriately” barely changed the rate of injuries. This category excludes inappropriate use––for example, someone trying to retrieve something from a box. We also compared the percentage of employees injured during disposal while using the old and new containers. Use of the old-style, straight-drop sharps container was associated with 68 disposal injuries during a 24-month period (Jan 1997–Dec 1998), or 2.83 per month and 34 a year. Use of the new-style, letterdrop sharps container was associated with 21 injuries in 18 months (Mar 1999–Aug 2000*), or 1.17 per month and 14 a year. When we adjusted this for the number of people at risk for needlestick injury, we had 9,386 persons at risk using the old straight-drop design and 10,394 after the design change, which translates into an injury percentage of .36% before the change and .13% after the implementation of the new containers. This was highly statistically significant (p = 0.002, chi square = 9.662). Before the change, staff were 2.9 times more likely to have a disposal injury than they were after the change. The new box reduced the injury percentage from .37% to .14%, which is a .23% decrease (95% confidence interval, .09%–.37%) In application, this means that if this were replicated in 100 different hospitals, the decrease in proportion injured would range between .09% and .37% in 95% of the hospitals. When adjusted to the number of employees, this translates into 24 fewer people with disposal injuries a year than with the original system. Had we not made the container change, we probably would have encountered a similar number of injuries year after year. VUMC’s annual rate of disposal injuries was reduced by two-thirds after the implementation of the new sharps container system in January 1999 (Figure 1). Data analysis did not extend beyond August 2000 because new safety products and educational and other initiatives introduced since then could also have been reflected in the data. The 18-month data collection period did not entail any other changes in products or processes that would have affected the comparison. Financial Impact A major factor in making a change is that many people do not think of the implication of the change on the system as a whole. For example, many people
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Sidebar. Cost Analysis of a Single Needlestick Injury Basic treatment: No drug therapy but includes testing of source patient: $532.48. Add 3 days of basic postexposure prophylaxis therapy and associated laboratory tests: $1,803.42. Add 4 weeks of drug therapy and hepatitis C or B and/or HIV (human immunodeficiency virus) source: $3,437.35 (total). Prior to implementing its emergency bloodborne standard, California’s Occupational Safety and Health Administration performed a comprehensive cost analysis on the use of safety needles. The report, released in December 17, 1998, estimated that each needlestick injury costs employers between $2,234 and $3,832.* On the basis of this information, we estimated that the average injury would cost $3,033. Reducing the number of injuries by 24 per year would result in a treatment savings of $72,792. Because the boxes cost $10,000 more than our old ones, the hospital would be realizing a cost savings of greater than $62,000. * American Medical Association, Council on Scientific Affairs: Preventing Needlestick Injury in Health Care Settings. Publication Report 1, Reference committee D. Chicago, 2000.
look at the cost of the product alone. In our case, changing to the new sharps containers had a projected product cost increase of $10,000 per year compared to using the straight-drop boxes. But product cost alone does not give a true picture of the financial impact of a change. VUMC’s occupational health division conducted a direct cost analysis of a single needlestick injury, which does not reflect lost productivity, time off, or risk management services (Sidebar, above). Nonfinancial Impact As great as the financial impact of purchasing safety devices and of a needlestick injury may be, the nonfinancial impact can be even greater. We desire the work environment to be as safe as possible for our staff. Financial calculations are based on a “best case” scenario. In reality, some of these employees could have converted to Hepatitis B or C, or HIV, the personal and financial impact of which would have been huge. Staff receiving preventive treatment after injury usually miss several days of work because of medication side effects. Needlestick injuries also have a terrible impact on the victim’s life. Just the titles of recent
7
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
413
THE JOINT COMMISSION articles on needlestick injuries convey the impact: “My needlestick,”6 “Post-traumatic stress disorder following needle-stick contaminated with suspected HIV-positive blood,”7 “Needlestick changes nurse’s life,”8 and “Nurse exposed to HIV to receive workers’ comp.”9
Discussion The fact that 16,000 health care workers annually receive needlesticks contaminated with HIV and that 600,000 to 1 million needlestick injuries to health care workers occur every year10 represents a huge impact on the health care system. At VUMC we are constantly striving to provide a safer work environment for our staff. This project is one example of a successful change. Our annual rate of disposal injuries was reduced by two-thirds after the implementation of the new sharps container system, and others should be able to replicate these results. Real-life, successful implementation of a safety product can be a very complex process. Reluctance to change is often a factor. Coordination and synchronization of all the steps, however thoroughly planned, do not always go as well as desired. For example, the sequence of training staff, having new brackets placed, and having new containers placed in brackets looked simple in the planning stage but proved to be a major complication and source of staff dissatisfaction. Some vendors are very willing to consider recommendations from customers to improve their prod-
414
ucts. We should be proactive rather than wait until we are victims. In many institutions, products are selected by purchasing agents or administration, in which case the products’ initial costs are often considered, but their overall value is not. As with many safety products, our experience is a good example of how an additional initial cost may yield savings. The most important lesson we learned was to keep focused on the vision of a safer environment for staff and ways to accomplish this. J * Data for January and February 1999 were excluded because of the need to ensure that implementation was complete throughout VUMC.
References 1. Hankin R: The real source of sharps injuries. Materials Management Aug 1996, p 38. 2. Anonymous: Getting a fix on sharps disposal containers. Nursing 29(11):78, 1999. 3. Jagger J, Bentley M: A sticky issue: Do sharps containers protect health care workers? Materials Management Aug 1996, pp 36–38. 4. Pugliese G: Reducing Sharp Injuries Among Health Care Workers (paper presented at the Premier Breakthrough in Performance Improvement Conference). St Petersburg, Nov 6, 2000. 5. Langley GJ, et al: The Improvement Guide: A Practical Approach to Enhancing Organiza-
tional Performance. San Francisco: Jossey-Bass, 1996. 6. Schwartz R: My needlestick. Am Fam Physician 60:329–331, Jul 1999. 7. Howsepian AA: Posttraumatic stress disorder following needle-stick contaminated with suspected HIV-positive blood. Gen Hosp Psychiatry 20:123–124, 1998. 8. Arnold L: Needle stick changes nurse’s life: Campaign for health care worker safety launched. PA Nurse 52(1):4, Jan 1997. 9. Nurse exposed to HIV to receive workers’ comp, The Tennessean, Nov 13, 1994, p B8. 10. Wilburn S: Preventing needlestick injuries. Am J Nurs 99:71, 1999.
J U LY 2002 J O U R N A L
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
Reducing Sharps Injuries Among Health Care Workers: A Sharps Container Quality Improvement Project IRENE B. HATCHER, MSN, RNC
S
harps injuries directly related to disposal in a safety container may seem like an oxymoron, but in 1997 Vanderbilt University Medical Center (VUMC; Nashville, Tenn) noticed a high incidence of injuries directly related to disposal. We undertook an analysis of the problem, implemented a change in sharps container style, and realized a significant reduction in needlestick injuries directly related to the disposal process. But the transition was not easy. What looked like a simple process proved to be very complex. This article provides a review of our journey.
Analyzing the Problem The VUMC administration has been committed to providing a safe environment for the staff and recognized the importance of implementing safety products as a way to reduce needlestick injuries. We at VUMC were early adopters of a needleless IV (intravenous) system in 1995. We began using the earliest version of “safety needles” and have continued to introduce new Irene B. Hatcher, MSN, RNC, is Chair of the Medical Cen-
ter Value Analysis Committee (VAC) and Coordinator of Case Management, Office of Case Management, Vanderbilt University Medical Center, Nashville, Tennessee. The author extends special thanks to Patricia Kinman, MSN, RN, CS, NP, Clinical Manager, Vanderbilt Occupational Health Copyright © 2002 by the Joint Commission on Accreditation of Healthcare Organizations
410
safety products as they have become available. We continuously reevaluate the products that are in use. Product selection at VUMC is made by its Value Analysis Committee (VAC), a multidisciplinary group whose purpose is to provide a systematic approach to the evaluation, selection, and standardization of patient care supplies and equipment, current and proposed, to ensure that the hospital is receiving the optimum benefit from all money spent. It also provides ongoing direction and education, and it creates policies for patient care supply and equipment utilization. Committee members consist of representatives from each of the clinical patient care centers divisions (for example, surgery, medicine, emergency, children’s) and from areas of special expertise such as biomedical engineering, IV therapy, infection control, and radiology. This committee composition ensures a great deal of clinical input in the selection of safety products. Although VUMC has used this model since 1994, many institutions have only begun to incorporate clinClinic, and Daniel W. Byrne, MS, General Clinical Research Center, Vanderbilt University Medical Center. Please address requests for reprints to Irene B. Hatcher, MSN, RNC, Office of Case Management, Vanderbilt University Medical Center A 1202 MCN, 1161 21st Ave S, Nashville, TN 37232-2415; phone 615/343/7944; fax 615/343-4866; e-mail [email protected].
J U LY 2002 J O U R N A L
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
JOURNAL
ON
QUALITY IMPROVEMENT
Article-at-a-Glance Background: Many needlestick injuries at Vanderbilt University Medical Center were found to be related to the method of disposal in sharps containers. The “straight-drop” system allowed staff to stuff more needles into a full box, resulting in needlestick injuries. This was also a common problem elsewhere, as reflected in the literature. Analyzing the problem: A multidisciplinary committee reviewed other sharps containers, piloted one, found problems, and then piloted and selected another. Implementation was complex and difficult, but focus was kept on the goal of decreased needlestick injuries. Staff identified other problems, which were
ical input because of recent Occupational Safety and Health Administration (OSHA; Washington, DC) regulations. Because the supply chain is so important in making products available, representatives from purchasing, inventory, and central supply/processing also are on the committee, as is a physician consultant. The problem, as the infection control coordinator advised other VAC members, was that many needlestick injuries were directly related to disposal into the sharps containers. We used the “straight-drop” system, which allowed staff to stuff more needles into a full box, resulting in needlestick injuries. Our experience was not unusual. For example, a report from the Exposure Prevention Information Network (EPINet™; Charlottesville, Va), a standardized system for tracking occupational blood exposures, stated that overfilled containers played a major role in these injuries.1 A literature review of the problem revealed that “as many as onethird of needlestick injuries happen during disposal of sharps. These injuries typically occur because of inappropriate placement or poor design of sharps containers and overfilling of containers.”2(p 78) A 1996 EPINet report showed that 16% of the cases of needlestick injuries occurred in introducing the sharps into disposal containers.3 A 1997 EPINet review of data from 55 hospitals showed that 15% of injuries were due to disposal4; at VUMC the proportion was 15.3% (see Figure 1, p 412) before we began to address the problem.
Addressing the Problem The VAC had tried several strategies in the previous months to address the problem of disposal-related
VOLUME
28
NUMBER
taken to the manufacturer of the sharps container selected and resulted in product design changes. Results: Several months after implementation, data analysis showed that the needlestick injury rate was reduced by two-thirds, a statistically significant change (p = 0.002). Despite the increased cost of the sharps container, savings of prevented needlestick injuries represented a total cost savings to the medical center of more than $62,000 a year. Discussion: This experience is an example of real-life implementation—and the problems institutions may have to overcome before success can be realized.
needlestick injuries. We had changed our sharps container from an opaque version to a translucent one, so that staff could see when the box was almost full. (With the opaque box, staff did not know the box needed to be emptied until it was completely full.) We worked with housekeeping on the importance of changing the boxes in a timely manner. None of these efforts made a difference, so we then used the Plan-Do-Study-Act (PDSA)5 model for quality improvement. Using the PDSA Model for Quality Improvement Plan: We reviewed other available sharps containers, which were then presented to the VAC. The VAC approved the “letter-drop” style system for piloting on selected units. VAC pilots products on areas of high use, high risk, or special expertise with products. In this case, we conducted the 2-week pilot studies in the cancer clinic, pediatric clinic, laboratories, emergency room, pediatric intensive care unit (ICU), and surgical ICUs. The pilot results were favorable, so medical center–wide implementation was planned. About a week before the implementation date, however, several VAC members attended a meeting on products with representatives from other hospitals. One of the hospitals reported serious complaints about the sharps container that we were about to use. Reportedly, if the box was closed too quickly, sometimes the sharps came back out like projectiles, causing injury. The reports were verified by a VAC member who had had that projectile experience using our chosen brand of sharps container at another institution. VAC
7
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
411
THE JOINT COMMISSION
Percentage
considered the reported problems, Disposal Injuries as a Percentage and after reevaluation, approved a of Total Needlestick Injuries pilot study on the same units of a 33.0% similarly designed box but made by a 35.0% different manufacturer. This second 30.0% 25.0% pilot was also successful. National 20.0% Do: We implemented the second 15% 15.3% 55 hospitals 15.0% type of “letter-drop” sharps containers VUMC 10.0% that we tested throughout VUMC. 5.9% VUMC 5.0% Many pieces of the implementation 0.0% plan needed to be synchronized. For Nursing EPINet 1/97– 3/99– ’99 ’97 12/98 8/00 example, new mounting brackets for Data Source and Period the sharps containers had to be installed before the boxes could be Figure 1. Vanderbilt University Medical Center (VUMC)’s annual rate of disposal injuries delivered to the units, and staff train- was reduced by two-thirds after the implementation of the new sharps container system in ing had to be complete before the January 1999. Source of data for EPINet™ from Jagger J, Bentley M: A sticky issue: Do boxes could be used. A major problem sharps containers protect health care workers? Materials Management Aug 1996, pp 36–38. occurred when plant operations did not realize the importance of its part in the overall drop to letter-drop containers. These hospitals scheme and had added another job as higher priority. reported similar initial acceptance problems but indiThis left some units with new sharps containers deliv- cated that sharps container–related needlestick ered and no brackets to put them in. Because we had a injuries did dramatically decrease at their institutions. “total swap out” type of implementation, the old boxes We were able to brave these implementation issues by were no longer available. focusing on our goal of reducing the incidence of needlestick injuries during the disposal process. Even Study: Soon after implementation of the new boxes, complaints came in on a product hotline to the though staff may not have liked the new sharps conpurchasing department; staff also reported problems tainers as well as the old ones, if we could reduce needlestick injuries, the conversion would be worth to VAC members: ■ The weight counterbalance in the containers did some initial dissatisfaction as staff accustomed themselves to the new boxes. not drop light-weight sharps; ■ The opening for sharps was too small if one had to We then repeated the PDSA cycle: ■ Plan: We evaluated the new design and the effect of insert multiple sharps, as in code situations; and ■ Bloody objects contaminated the “shelf ” (the area the change on injuries. ■ Do: As soon as the redesigned containers became where sharps lay before dropping into the container). Overall, staff were not very happy with the new available commercially, we implemented them on sharps containers. VUMC units. ■ Study: We conducted a staff satisfaction survey and Act: On the VAC’s recommendation, the purchasing department reported the complaints to the sharps monitored needlestick injuries related to disposal. container manufacturer. Although customers frequently ■ Act: We decided to continue to use the redesigned do not take this step, thinking their efforts would be sharps containers. futile, this particular company was very receptive. Within approximately 3 months, the company Results redesigned the sharps container, adjusting the counter- Sharps injuries are categorized by our occupational weight to empty light objects and enlarging the opening. health staff in terms of the activity being performed at the time of the injury and the product being used. These staff then attempt to determine if the injury was Repeating the PDSA Cycle The infection control coordinator consulted avoidable or unavoidable. Categorizing the injuries as other hospitals that had also converted from straight- those “that could have been prevented if the sharps
412
J U LY 2002 J O U R N A L
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
JOURNAL
ON
QUALITY IMPROVEMENT
container had been used appropriately” barely changed the rate of injuries. This category excludes inappropriate use––for example, someone trying to retrieve something from a box. We also compared the percentage of employees injured during disposal while using the old and new containers. Use of the old-style, straight-drop sharps container was associated with 68 disposal injuries during a 24-month period (Jan 1997–Dec 1998), or 2.83 per month and 34 a year. Use of the new-style, letterdrop sharps container was associated with 21 injuries in 18 months (Mar 1999–Aug 2000*), or 1.17 per month and 14 a year. When we adjusted this for the number of people at risk for needlestick injury, we had 9,386 persons at risk using the old straight-drop design and 10,394 after the design change, which translates into an injury percentage of .36% before the change and .13% after the implementation of the new containers. This was highly statistically significant (p = 0.002, chi square = 9.662). Before the change, staff were 2.9 times more likely to have a disposal injury than they were after the change. The new box reduced the injury percentage from .37% to .14%, which is a .23% decrease (95% confidence interval, .09%–.37%) In application, this means that if this were replicated in 100 different hospitals, the decrease in proportion injured would range between .09% and .37% in 95% of the hospitals. When adjusted to the number of employees, this translates into 24 fewer people with disposal injuries a year than with the original system. Had we not made the container change, we probably would have encountered a similar number of injuries year after year. VUMC’s annual rate of disposal injuries was reduced by two-thirds after the implementation of the new sharps container system in January 1999 (Figure 1). Data analysis did not extend beyond August 2000 because new safety products and educational and other initiatives introduced since then could also have been reflected in the data. The 18-month data collection period did not entail any other changes in products or processes that would have affected the comparison. Financial Impact A major factor in making a change is that many people do not think of the implication of the change on the system as a whole. For example, many people
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Sidebar. Cost Analysis of a Single Needlestick Injury Basic treatment: No drug therapy but includes testing of source patient: $532.48. Add 3 days of basic postexposure prophylaxis therapy and associated laboratory tests: $1,803.42. Add 4 weeks of drug therapy and hepatitis C or B and/or HIV (human immunodeficiency virus) source: $3,437.35 (total). Prior to implementing its emergency bloodborne standard, California’s Occupational Safety and Health Administration performed a comprehensive cost analysis on the use of safety needles. The report, released in December 17, 1998, estimated that each needlestick injury costs employers between $2,234 and $3,832.* On the basis of this information, we estimated that the average injury would cost $3,033. Reducing the number of injuries by 24 per year would result in a treatment savings of $72,792. Because the boxes cost $10,000 more than our old ones, the hospital would be realizing a cost savings of greater than $62,000. * American Medical Association, Council on Scientific Affairs: Preventing Needlestick Injury in Health Care Settings. Publication Report 1, Reference committee D. Chicago, 2000.
look at the cost of the product alone. In our case, changing to the new sharps containers had a projected product cost increase of $10,000 per year compared to using the straight-drop boxes. But product cost alone does not give a true picture of the financial impact of a change. VUMC’s occupational health division conducted a direct cost analysis of a single needlestick injury, which does not reflect lost productivity, time off, or risk management services (Sidebar, above). Nonfinancial Impact As great as the financial impact of purchasing safety devices and of a needlestick injury may be, the nonfinancial impact can be even greater. We desire the work environment to be as safe as possible for our staff. Financial calculations are based on a “best case” scenario. In reality, some of these employees could have converted to Hepatitis B or C, or HIV, the personal and financial impact of which would have been huge. Staff receiving preventive treatment after injury usually miss several days of work because of medication side effects. Needlestick injuries also have a terrible impact on the victim’s life. Just the titles of recent
7
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
413
THE JOINT COMMISSION articles on needlestick injuries convey the impact: “My needlestick,”6 “Post-traumatic stress disorder following needle-stick contaminated with suspected HIV-positive blood,”7 “Needlestick changes nurse’s life,”8 and “Nurse exposed to HIV to receive workers’ comp.”9
Discussion The fact that 16,000 health care workers annually receive needlesticks contaminated with HIV and that 600,000 to 1 million needlestick injuries to health care workers occur every year10 represents a huge impact on the health care system. At VUMC we are constantly striving to provide a safer work environment for our staff. This project is one example of a successful change. Our annual rate of disposal injuries was reduced by two-thirds after the implementation of the new sharps container system, and others should be able to replicate these results. Real-life, successful implementation of a safety product can be a very complex process. Reluctance to change is often a factor. Coordination and synchronization of all the steps, however thoroughly planned, do not always go as well as desired. For example, the sequence of training staff, having new brackets placed, and having new containers placed in brackets looked simple in the planning stage but proved to be a major complication and source of staff dissatisfaction. Some vendors are very willing to consider recommendations from customers to improve their prod-
414
ucts. We should be proactive rather than wait until we are victims. In many institutions, products are selected by purchasing agents or administration, in which case the products’ initial costs are often considered, but their overall value is not. As with many safety products, our experience is a good example of how an additional initial cost may yield savings. The most important lesson we learned was to keep focused on the vision of a safer environment for staff and ways to accomplish this. J * Data for January and February 1999 were excluded because of the need to ensure that implementation was complete throughout VUMC.
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tional Performance. San Francisco: Jossey-Bass, 1996. 6. Schwartz R: My needlestick. Am Fam Physician 60:329–331, Jul 1999. 7. Howsepian AA: Posttraumatic stress disorder following needle-stick contaminated with suspected HIV-positive blood. Gen Hosp Psychiatry 20:123–124, 1998. 8. Arnold L: Needle stick changes nurse’s life: Campaign for health care worker safety launched. PA Nurse 52(1):4, Jan 1997. 9. Nurse exposed to HIV to receive workers’ comp, The Tennessean, Nov 13, 1994, p B8. 10. Wilburn S: Preventing needlestick injuries. Am J Nurs 99:71, 1999.
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Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations