Building better programs to prevent transmission of blood-borne pathogens to healthcare personnel: progress in the workplace, but still no end in sight.

In 2001, there were an estimated 9.2 million individuals working in healthcare in the United States.1 Despite the use of standard precautions and the introduction of safety-engineered devices, healthcare workers remain at substantial risk of occupational exposure to blood-borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Estimates of the annual number of percutaneous injuries among U.S. healthcare personnel vary widely but represent a substantial occupational risk. Using national occupational health surveillance data from 1997 and 1998, Panlilio et al. estimated that in the United States there were approximately 384,000 percutaneous injuries annually among hospital-based healthcare workers.2 Despite effective pre-exposure and postexposure prophylaxis for HBV and recent revised recommendations for postexposure prophylaxis after HIV exposure, the best approach to prevent occupational blood-borne infection is the prevention of percutaneous injuries associated with medical devices contaminated with blood. In September 1998, California became the first U.S. state to implement a safe needle device act to decrease the risk of occupational percutaneous injuries. Currently, more than 17 other states have passed similar legislation. In November 2000, the federal Bloodborne Pathogen Safety Act was signed into law, and as of April 30, 2002, the Joint Commission on Accreditation of Healthcare Organizations required full compliance with this act. If properly used, safety devices can be an effective means of reducing the number of percutaneous injuries. In a large study conducted by investigators from the Centers for Disease Control and Prevention and 10 U.S. teaching hospitals during 1993 to 1995, use of phlebotomy devices with safety features significantly reduced phlebotomy-associated percutaneous injuries and was associated with minimal adverse events.3 Activation rates of the safety feature varied according to ease of use, healthcare worker preference, perceived patient adverse events (such as hematoma formation and need for repeat phlebotomy), and devicespecific training. Despite a study demonstrating that use of blunt suture needles decreased the risk of percutaneous exposure during gynecologic surgical procedures, acceptance of these devices in surgical practice remains poor.4 Healthcare facilities can use many types of safetyengineered devices to reduce the number of percutaneous injuries, but these devices have limitations and obstacles to full implementation remain. There is a growing and bewildering assortment of safety devices currently being marketed, some of which require user activation and others with automatically activated safety features. They vary considerably in their ease of use and effectiveness in reducing injury rates, and are not available for certain situations, such as dentistry and arterial line placement. Training and education are necessary to ensure proper use. The increased direct cost of safety devices is another potential obstacle to implementation. The added cost of a needle with a safety feature ranges from pennies for a blood collection needle or syringe with a needle attached to more than $0.70 for an intravenous catheter. The annual cost to a healthcare facility to comply with the federal Safe Needle Device Act is not trivial. Following implementation of the California Safe Needle Device Act in 2000, we estimated that the added cost for safety features for our hospital increased the annual expenditure for needle-containing devices 50%, from $412,000 in 1999 to $825,000 in 2000.5 The benefits of needles with safety features appear to