**Department of** **Memorandum**

**Veterans Affairs**

Date: February 28, 2003

From: Deputy Under Secretary for Health for Operations and Management
(10N)

Subj: Preliminary Review of Bloodborne Pathogens Performance Monitor
Results

To: Network Directors (10N1-23)

CC: Network Quality Management Officers

Network Chief Medical Officers

1\. In 2001, the Occupational Safety and Health Administration (OSHA)
promulgated the Safe Needle Act, which modified the Bloodborne Pathogens
standard (OSHA 1910.1030). This Act required facilities to replace
devices which may cause exposure to blood or body fluids with "safer"
devices, that must meet certain FDA criteria; to involve front-line
workers at the facility level in the selection of such devices; to post
the injury information in a dedicated Sharps Injury Log, while
protecting the identify of injured employees; and to review the Exposure
Control plan annually, in an attempt to speed up replacement of safer
devices. Some hospitals have been cited for using devices that are
currently being marketed as "safer" although they fail to meet FDA's
criteria, suggesting that careful review and front-line worker
involvement is essential. VHA set a performance monitor for FY2002 on
bloodborne pathogens. The components of this monitor include:

a.  Replacing at least three devices causing injuries

b.  Submitting exposure control plans as reviewed in FY2002

2\. VHA has long been a leader in bloodborne pathogens injury reduction.
OSHA recently approached VHA to work on implementation issues and
develop a joint satellite broadcast, which is currently accessible from
OSHA's website in streaming video. This reflects VHA's leadership in the
field of health care worker occupational health. In preparation for that
broadcast, VHA inquired about implementation difficulties through
informal calls to various professional groups. In addition, VHA has
information from the 2001 All Employee Survey and from its in-house
injury reporting system. These were reviewed together with the data
responses to the performance monitor to prepare the summary below.

3\. Responses submitted by 134 hospital systems from all twenty-one
VISNs were available for this initial analysis. Results include the
following:

a.  In FY2002, facilities replaced an average of 6.2 devices (standard
    deviation: 4.8)

b.  There was no difference in the number of devices replaced by large
    or small facilities (mean differences: average 5.8 in smallest
    quartile of facilities, average 6.2 in largest quartile of
    facilities)

c.  In FY2001 and before, facilities had replaced an average of 13.5
    devices (standard deviation: 7.6)

d.  Large facilities had replaced significantly more devices than small
    facilities (largest quartile average: 13.5, smallest quartile
    average10.0)

e.  Several facilities have replaced so many devices that they were
    unable to identify three additional devices for replacement in
    FY2002. Those facilities are to be commended. They were: White River
    Junction, Bath, Indianapolis, Northern Indiana, Honolulu, Palo Alto,
    and San Francisco.

f.  Some facilities have replaced devices without involvement of
    front-line workers and without adequate training of staff in device
    usage. Although facilities are to be commended for the eagerness,
    such implementation strategies do not meet the requirements of the
    OSHA standard and may cause increases in injury rates.

4\. Attached are tables reflecting:

a.  Whether VISNs met or did not meet the performance monitor in FY2002.
    Some of the individual facilities that did not replace all devices
    were still in the process of trialing or of purchasing devices.

b.  The number of devices replaced by VISN in FY2002 and FY2001 or
    before by Facility Size

5\. Bloodborne pathogens injuries rank among the most frequent injuries
in VHA, representing 19% of events reported in ASISTS (Figure 1).
Although this appears high, the 2001 All Employee survey suggested VHA
employees experience between 35,000 and 50,000 bloodborne pathogens
injuries in FY2001. The occupations at highest risk of bloodborne
pathogens injury in VHA were surgeons and dentists (see figure 2),
although nurses experience over 50% of the bloodborne pathogens injuries
in VHA. The types of injuries vary for these groups and are included in
Attachment 1.

In accordance with the new OSHA guidelines, dental, surgical, nursing
staff should continue to monitor and evaluate new and existing products
which could help prevent sharps injuries in the work environment (i.e.
new \"safety needles\" ). In addition, new equipment designs may
minimize exposure to sharps.

6\. In the course of the satellite broadcast, field questions and OSHA
responses suggest the following additional information may be useful

a.  OSHA expects to see ongoing efforts to replace devices, based on
    annual reviews of injuries. OSHA recognizes that replacing devices
    is a time-consuming process. If facilities are actively replacing
    devices as evidenced by the presence of a committee (evaluating,
    trailing, replacing) that is doing things (replaced devices in use
    in the facility) OSHA is not likely to cite. (We are happy to
    support citation challenges where those occur in such settings).

b.  The Safe Needle Act mandates that frontline workers be involved in
    selecting devices. OSHA will view standardization across facilities
    (by VISN) as not meeting the requirements of the Act

c.  Trialing and selecting devices and then not purchasing them will be
    viewed by OSAH as a violation of the law

d.  A new CD-ROM is under development in West Haven for training on
    bloodborne pathogens. Please feel free to log on
    ([**http://208.34.95.23/base/courses**](http://208.34.95.23/base/courses)
    ) recognizing this is still under development, and comment back to
    Drs Esther Nash and, Paul Heller or Robert Lucas (in Outlook)

7\. VHA has implemented abroad range of programs to reduce bloodborne
pathogens injuries, reflecting its position of national leadership.
These programs have had a clear and demonstrable effect: facilities and
areas with a higher prevalence of safer devices clearly have lower
bloodborne pathogens injury rates than those with fewer devices in use.
Thanks for your good work and for your efforts in providing a safe
workplace for employees. Such a focus on safety represents a major
commitment to being an employer of choice.

/Signed/

Laura J. Miller

Attachments

Table 1: Device replacement by facility size

Table 2: VISN Reporting of devices replaced in FY2002 or in FY2001 and
before

Figure 1: ASISTS cumulative data 1998-2001

Figure 2: Bloodborne pathogens injuries by occupational group

Figure 3: Bloodborne pathogens injury by "safety" device use penetration

Attachment 1 -- the 3 VHA occupations with the most frequent injuries

Table 1: Device replacement by facility size

+---------------------+-----------------------+-----------------------+
| # Fa                | did not replace 3 or  | replaced three or     |
| cility size in FTEE | more devices          | more devices          |
+---------------------+-----------------------+-----------------------+
| **Less than 685**   | 20.6%                 | 79.4%                 |
+---------------------+-----------------------+-----------------------+
| **688-1160**        | 14.7%                 | 85.3%                 |
+---------------------+-----------------------+-----------------------+
| **1161 - 1690**     | 21.2%                 | 78.8%                 |
+---------------------+-----------------------+-----------------------+
| **1691 - 3600**     | 27.3%                 | 72.7%                 |
+---------------------+-----------------------+-----------------------+
| **Average**         | 20.9%                 | 79.1%                 |
+---------------------+-----------------------+-----------------------+

Table 2: VISN Reporting of devices replaced in FY2002 or in FY2001 and
before

  ----------------- -------------------------- --------------------------
  VISN              Devices replaced in 2002   Devices replaced in 2001
                                               or earlier

  **1**             43                         106

  **2**             28                         20

  **3**             39                         59

  **4**             78                         179

  **5**             17                         46

  **6**             37                         97

  **7**             30                         73

  **8**             34                         110

  **9**             31                         130

  **10**            13                         48

  **11**            46                         91

  **12**            45                         89

  **15**            28                         70

  **16**            83                         158

  **17**            33                         53

  **18**            58                         68

  **19**            40                         75

  **20**            43                         77

  **21**            37                         110

  **22**            21                         84

  **23**            50                         80

  **Grand Total**   834                        1823

                                               
  ----------------- -------------------------- --------------------------

> Figure 1
>
> ![](media/image1.wmf)
>
> Figure 2
>
> ![](media/image3.wmf)
>
> ![](media/image5.pct)

Figure 3

![](media/image7.wmf)

Attachment 1

**Dentistry:** One of the most frequent extra-oral injuries result from
dental burrs (drills) left in the hand pieces (these are considered
\"sharps injuries\". Needlestick injuries also occur during the
administration of local anesthetic, during uncapping/recapping
procedures and even during cleanup (removal of needles from syringes).
Other sharps injuries also occur (i.e. from blades, numerous sharp
dental instruments) in dentistry. Possible solutions for these causes
include, but are not limited to:

i.  dental burrs: remove the burr after use (work practice control),
    using bur cassettes when storing burs and new equipment design by
    manufacturers which reduces exposure of sharp dental burs
    (engineering controls).

ii. Anesthetic syringes/needles: Use of uncapping/recapping devices when
    injecting local anesthetic (2 handed recapping of the dental
    anesthetic syringe violates both OSHA BBP regulations and VA Dental
    Infection Control Guidelines).

iii. Continued use of existing personal protective equipment in
     dentistry (i.e. heavy duty rubber gloves during cleanup, blade
     removal devices, eye protection, instrument retractors in the oral
     cavity, etc).

**Surgery:** Common causes of injury include: sharps injuries (needles,
scalpels) during instrument transfer, suture needle injuries, and other
sharps (scalpels) injuries. Several specific interventions and two
specific strategies have been identified in facilities, and documented
in the peer-reviewed literature, to have some benefit. Such strategies
must be considered very carefully, as many are not appropriate for all
settings or procedures. The implications for duration of surgery, the
risks to patients and staff from uncomfortable devices, and the duration
of time to implement solutions must be considered very carefully.
Affected staff must be involved in trialing these strategies, and such
strategies may not be implemented against their judgment. Still, the
following have been useful

iv. Work practices: the use of \"hands-free\" or \"instrument
    transfer/passing\" zones clearly reduces injuries. Double gloving
    may protect against exposure, but further scientific work remains to
    be done to show these conclusively.

v.  Devices: The use of blunt suture needles and of \"safer\" scalpels
    may lead to a decreased injury frequency of injuries, based on some
    published literature.

vi. Implementation: Implementing these solutions requires institutional
    commitment and \"felt\" leadership in the operating room, as
    provided by chiefs of surgery or chief nurses in the operating room.

**Nursing:** Nursing comprises a large and varied group of individuals,
with a broad range of tasks and risks. Injections through the skin and
direct venous sticks (injections, lines, and blood-drawing) represent
the most common forms of injury. Strategies to address these injuries
must be developed at the local level, as the underlying causes and
reasons differ from facility to facility.