By Kelly M. Pyrek
This article originally appeared in the August 2022 issue of Healthcare Hygiene magazine.
Even as the healthcare sector begins to expand its former laser focus on respiratory infections only due to the COVID-19 pandemic, recently released data indicate the need to keep sharp object injuries and blood and body fluid exposures from falling off the collective radar.
Ensuring the occupational health of caregivers is part of the Centers for Disease Control and Prevention (CDC)’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. These recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) call for ensuring that healthcare personnel either receive immunizations or have documented evidence of immunity against vaccine-preventable diseases; implement processes and sick leave policies to encourage healthcare personnel to stay home when they develop signs or symptoms of acute infectious illness; and implementing a system for healthcare personnel to report signs, symptoms, and diagnosed illnesses that may represent a risk to their patients and coworkers. It also recommends adherence to “federal and state standards and directives applicable to protecting healthcare workers against transmission of infectious agents, including OSHA’s Bloodborne Pathogens Standard, Personal Protective Equipment Standard, Respiratory Protection standard and TB compliance directive.”
As the CDC notes, “Healthcare personnel can be exposed to potentially infectious blood, tissues, secretions, other body fluids, contaminated medical supplies, devices, and equipment, environmental surfaces, or air in healthcare settings. Mechanisms of occupational exposures include percutaneous injuries such as needlesticks, mucous membrane or non-intact skin contact via splashes or sprays, and inhalation of aerosols. Healthcare personnel can also be exposed to infectious diseases in the community and risk transmitting them to others at work. Appropriate management of potentially infectious exposures and illnesses among healthcare personnel can prevent the development and transmission of infections. Effective management of exposures and illnesses includes promptly assessing exposures and diagnosing illness, monitoring for the development of signs and symptoms of disease and providing appropriate post-exposure or illness management. Providing exposure and illness management services also affords the opportunity for counseling to address healthcare personnel concerns about issues such as potential infection, adverse effects of postexposure prophylaxis, and work restrictions.”
The CDC adds that a substantial number of potentially infectious exposures occur in the workplace, despite longstanding regulations and guidelines in place for their prevention and providing timely and effective exposure management services can be challenging. Bloodborne pathogen exposures among healthcare personnel are significantly underreported, some experts say. Time constraints, fear of reprimand, lack of information on how to report exposures, and cost coverage of exposure management have been identified as factors in not reporting exposures. While many healthcare personnel may be guaranteed cost coverage for job-related exposure and illness by workers’ compensation laws, not all healthcare personnel, such as volunteers and trainees, may have this benefit.
One strong advocate for the occupational health of care providers is the International Safety Center (ISC), which focuses on collecting and analyzing data that better identifies healthcare worker safety hazards. The ISC helps healthcare institutions measure blood and body fluid exposures, sharps injuries and needlesticks to help prevent worker exposures to dangerous pathogens. The Center’s Exposure Prevention Information Network (EPINet) surveillance system has provided healthcare facilities with a standardized system for tracking the occupational exposures that put healthcare staff at risk.
The latest reports from EPINet tell the story.
The 2021 Sharp Object Injury Report provides data from the reporting period of Jan 1, 2021 to Dec 31, 2021 and information is collected from 41 hospitals participating. Out of 1,660 records, 16.2 percent of physicians who were interns, residents or fellows sustained sharp-object injuries, as did 14.7 percent of attending or staff physicians. Nurses fared worse, with 39.4 percent of them being injured. The report shows that 2.9 percent of allied healthcare professionals such as phlebotomists were injured, as were 1.6 percent of certified nursing assistants. Approximately 1 percent of environmental services workers were injured by a sharp object during the performance of their duties. Out of 1,647 records, 37.4 percent of these injuries happened in the operating room; 30 percent of these injuries occurred in a patient room; 8 percent in the emergency department, 2.5 percent in the ICU or critical care unit, and the rest occurring in various other areas of the healthcare environment. The source patient was identifiable in 91.7 percent of the injuries, and in 74.5 percent of cases, the healthcare professional was injured. In 89.5 percent of the cases the sharp object was considered to be contaminated, and blood was visible on the sharp in 69.5 percent of cases. An injection was responsible for the injury in 29.2 percent of cases, and suturing in 27.5 percent of cases. Injuries occurred during use of the sharp object in 57.5 percent of cases. Notably, in 62.4 percent of cases, the item causing the injury was a needle or sharp medical device not considered to be a safety design with a shielded, recessed, retractable, or blunted needle or blade.
The EPINet Report for Blood and Body Fluid Exposures, with data collected from the same time period, shows that in 55.6 percent of 554 records from 41 hospitals, nurses were the ones exposed, followed by 16.4 percent of physicians. The data show that 40.9 percent of these exposures occurred in the patient room, followed by 21.9 percent in the operating room, 12.1 percent in the emergency department, and the rest occurring elsewhere in the healthcare facility. The source patient was identifiable in 92.7 percent of cases, and blood or blood products were involved in 58 percent of cases. Of 376 records, eyes (conjunctiva) were exposed in 73.1 percent of cases, and blood and/or body fluids touched unprotected skin in 74.1 percent of cases, raising the alarm among safety experts.
The continued lack of eye protection is concerning for decades that EPINet data has been collected from network facilities, says Amber Hogan Mitchell, DrPH, MPH, CPH president and executive director of the International Safety Center. “We publish data publicly every year and it continues to be frustrating that people don’t seem to pay attention to it. Over the past few years, exposures to the head and face make up about 80 percent of all exposure incidents reported and the greatest majority of those are to unprotected eyes. This past year, eye protection use is a tad improved, but still only 11.2 percent of workers indicate they are wearing protective eyewear or face shields. In years past it was a low as 3 percent. Infection preventionists have focused more in the past on protecting a patient from a worker when a patient is in isolation or on contact precautions. Occupational health officers focused more on protecting a worker and using PPE for chemical, radiologic, or physical hazards. It is now glaringly obvious that the two need to come together, broaden focus and create synergies. This means making protective eyewear and face shields available when and where needed. It is not enough for them to be on infection control or isolation carts, but also in patient and procedure rooms.”
According to EPINet data, most blood/body fluid exposures occurred while healthcare personnel were wearing a surgical mask (73 percent) or single pair of gloves (60.5 percent). Personnel were wearing a double pair of gloves in 11.1 percent of cases, non-protective eyeglasses in 11. 1 percent of cases, and protective eyewear/goggles in 5.1 percent of cases. A face shield was worn in only 3.4 percent of exposures. And less than 1 percent of healthcare workers were wearing any other items of personal protective equipment (PPE) at the time of the exposure.
As OSHA’s Bloodborne Pathogen Standard mandates, “Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.”
“Making PPE, including protective eyewear, goggles, and face shields visible and available is a cue to action for workers that a risk has been identified and it should be worn,” Mitchell says. “PPE should not be primarily housed in a closet down the hall or a cart that needs to be rolled around. It should be placed in wall mounts or prominent locations within a unit or department. Additionally, since so many of us need corrective lenses, a variety of products should be available to be used so that one does not need to compromise sight for safety and vice versa.”
Lack of PPE usage remains a significant concern not only for COVID-19 infection, but for blood and body fluid exposure as well as exposure to other opportunistic pathogens in the healthcare setting. As the International Safety Center (2027) observes, “According to EPINet data, compliance with PPE use when an exposure to blood, body fluid, or biologic hazard occurs is lower than ideal. It can range from more than 70 percent (glove use) to less than 2 percent (goggle use), depending on the body location and type of incident. Even when PPE is worn to protect a worker from an exposure or contamination, studies indicate that upon removal a worker contaminates him/herself almost half of the time. The most frequent self-contamination occurs on the hands, forearms, neck, and face, as well as in hair and on clothing (Tomas, JAMA Intern Med 2015).”
The OSHA Bloodborne Pathogen Standard says that “When there is occupational exposure, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered ‘appropriate’ only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.
Further, OSHA indicates that “The employer shall ensure that the employee uses appropriate personal protective equipment unless the employer shows that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee's professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgement, the circumstances shall be investigated and documented to determine whether changes can be instituted to prevent such occurrences in the future.”
OSHA also mandates accessibility: “The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.”
Mitchell says a paradigm shift is needed. “In my opinion, facilities should motivate good and safe practices by rewarding employees with eye and face protection that they are as proud to wear as a lab coat or embroidered scrubs,” she says. “Perhaps providing protective eyewear in multiple colors and styles and giving vouchers for protective eyewear with corrective lenses. Every manufacturing floor I’ve been on has a thick yellow line to indicate that you must not step past it without some kind of PPE – either a hard hat, hearing protection, eye protection, reflective wear, or all. In healthcare, we seem to only have blurred, gray lines. That needs to change.”
Human behavior being what it is, the Hierarchy of Controls, developed by industrial hygienists and safety professionals is designed to provide a structure that guides the most effective means of isolating a hazard, which is to eliminate it, and works through several levels of additional controls. Because biological hazards like the ones faced by healthcare personnel daily cannot readily be eliminated, the next best control is to engineer the hazard out – ranging from safer medical devices that protect workers from a needle or sharp object, to closed systems used for suctioning and HEPA-filtration in HVAC systems.
When a hazard cannot be eliminated or engineered out, it is then that professionals rely on safe work practices, administrative controls, and the use of PPE, according to ISC (2017): “These controls are highly dependent on personal and professional behavior, training, education, availability and access, adequate staffing, and the overall anticipation of hazard being likely to occur. We have already indicated that PPE use and compliance is low during an exposure with blood and body fluids, often times because that exposure is not anticipated and a worker cannot adequately prepare for it. This in part is because all factors may not be in place to create the safest environment. In short, it is difficult to create reliable systems of protection if there are too many opportunities for that system to fail – exposures are not anticipated, PPE use is low even when they are anticipated, and PPE when worn during anticipated exposures is unreliable.”
To close this chasm between policy and implementation, ISC (2017) points to the need for manufacturers to recognize these exposures as “an opportunity to create products that fill a need and narrow a gap to protect workers exposed to blood, body fluids, and other biologic hazards … Manufacturing and purchases of these alternatives are ramping up. It is the time to make sure that they are done safely, appropriately, and with the utmost quality so that they best protect the workers that wear them.”
A longstanding example has been safety-engineered medical devices such as safety syringes and suturing needles, as part of the engineering and work practice control. OSHA’s BloodBorne Pathogen Standard states that “Engineering and work practice controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used.”
The EPINet data show that there wasn't an increase in the use of devices with engineering controls, so some are asking whether clinicians can apply pressure to manufacturers to make better devices and provide additional training, and how can healthcare facilities drive higher compliance not only with safety-engineered devices but use of all elements of PPE.
“The pressure shouldn’t so much be on clinicians to apply pressure externally to manufacturers, but for employers to comply with the OSHA Bloodborne Pathogens Standard and work within their distribution networks on finding devices best suited to preventing injuries based on what their frontline staff have evaluated and selected,” Mitchell emphasizes. “While the 2000 Needlestick Safety and Prevention Act brought renewed focus on the importance of using sharps injury prevention devices, the requirement to use engineering controls to prevent exposure to blood and body fluids has been in place since 1992. Clinicians don’t need additional burdens; they need their employers and leaders to decide that complying with federal regulations matters to them.”
Mitchell continues, “One of the long-time, intentionally-designed benefits of EPINet is being able to provide not only internal decisionmakers, but external partners like manufacturers and distributors with information about what devices are causing injuries, whether they had “safety” features or not, whether they were activated, and disposed of safely. EPINet is free for anyone to use, and it can be a terrific tool to help document what devices may need to be evaluated or re-evaluated by frontline workers using them.”
“Our EPINet network facilities continue to help us drive national and international awareness about the importance of incident and exposure surveillance for sharps injuries, needlesticks, and mucocutaneous (blood and body fluid) exposures”, says Ginger B. Parker, the Center’s chief information officer and deputy director. She continues, “based on experiences and data from our EPINet network facilities, we can help to shape and improve the public health landscape to reduce ongoing endemic levels of HCV and HIV and prepare for whatever challenges are ahead.”
The International Safety Center (2017) has identified key areas to make progress in reducing the risk of occupational exposure to infectious microorganisms, specifically related to work attire worn in healthcare settings.
The first key issue is understanding the role of work wear and occupational exposure to Infectious disease and biologic hazards. The ISC (2017) recommends that:
• New work wear contamination data collected in clinical settings is shared with government agencies including OSHA, NIOSH, CDC, and others so that they have the most up-to-date information to consider in updating their worker safety and health standards, guidance, and recommendations
• Health and Human Services agencies such as CDC/NIOSH and other government and non-governmental agencies and professional organizations support epidemiological research that evaluates risks to workers as it relates to the role of work wear occupational exposure to infectious disease
• Professional groups and manufacturers join forces to encourage development of work wear that provides the best protection for workers when they are not wearing PPE or barrier garments
• Institutions adopt policies that include measuring blood and body fluid exposures to identify incidence of work wear contamination
The second key issue is reducing occupational exposures by improving compliance with and the protective factor of PPE and barrier garments for anticipated exposures. As ISC (2017) points out, “Occupational surveillance data capturing splash and splatter incidents from the EPINet network of U.S. hospitals indicates that when exposures do happen, employees are infrequently wearing PPE or barrier garments that prevent blood and body fluids from touching skin or mucous membranes.” The ISC (2017) recommends that:
• Health and Human Services agencies such as CDC/NIOSH and other government and non-governmental agencies and professional organizations support epidemiological research that evaluates compliance of PPE use and programs that support improving PPE use
• Professional organizations and medical product distributors collaborate to make PPE use and work wear a priority and ensure that educational and training materials are available to their members and customers
• Accrediting and licensing bodies and healthcare and workers’ compensation insurers enhance compliance incentives for employers with specific PPE and work wear programs in place
• Institutions record PPE use on incidents of employee blood and body fluid exposure reports
The third key issue is increasing consideration of work wear as an engineering control for unanticipated exposures. As ISC (2017) observes, “More than 80 percent of blood and body fluid exposures to skin and mucous membranes were not from gaps or soak through in protective garments. It can be inferred that these exposure incidents are from exposures that were not anticipated and therefore the employee was not prepared and was therefore not wearing PPE (other than gloves) or barrier garments at all.” The ISC (2017) recommends recommend that:
• Health and human services organizations and professional organizations partner with device manufacturers to assess and prioritize needs for specific work wear technologies (active barrier, fluid repellent, antimicrobial), their clinical applications, monitor progress in closing existing gaps, and to identify future needs
• Institutions identify if PPE is immediately accessible in all locations that exposures are occurring
• Institutions evaluate commercially available work wear technologies and implement them where feasible
The fourth key issue is determining the best path forward for developing and implementing consensus standards for work wear. As the ISC (2017) notes, “Controls are in place to protect both patient and worker, including the use of diagnostics, standard precautions, engineering controls, and personal protective equipment; however, growing evidence in the peer-reviewed literature and consensus from agencies like OSHA tells us that current controls are not adequately preventing the spread of pathogens on surfaces and affiliated with textiles or garments, therefore we must explore new and innovative approaches. Since new protective textile technologies, innovative engineering controls, and PPE are gaining traction in the marketplace, efforts need to focus on identifying the most important design and performance parameters for the soft surfaces and textiles that play a growing role in the transmission of infectious pathogens and relevant occupational hazards.” The ISC (2017) recommends:
• Convene expert panel to review, discuss, and propose considerations for standards setting groups like ASTM, AAMI, and ISO; regulatory agencies including FDA, OSHA, EPA; and professional organizations such as AORN, APIC, SHEA, AATCC, and others, with the panel to include experts from multi-disciplinary fields, including epidemiology, infectious disease, textile production, quality, academia, labor unions, and technical fields
• Explore the development and execution of a consensus standard defining the performance parameters of a new textile classification for active barrier apparel.
It’s a tall order in ordinary times; coming off a two-year pandemic, Mitchell says she believes the COVID era is here to stay, possibly adding to the challenges of raising the profile of prevention of sharp object injury and blood/body fluid exposures.
“I think that it will be like many other pathogens and become endemic,” Mitchell emphasizes. “Emergence may mean rather that with all controls and protective measures that we keep in place, that we keep it and whatever is after it at bay. It is important to remain diligent about preventing exposures to bloodborne pathogens and not sacrificing protections from one for the other. We encourage manufacturers and distributors to use our 2021 EPINet data as free and meaningful market data. Year after year, we know what devices are continuing to cause injuries, even during activation and we know what PPE is continuing to not be worn. If manufacturers and distributors work in partnership with us, we can help to close those gaps – like improving use of devices with sharps injury prevention features and needleless systems and eye protection use -- and diminish risks of both sharps injuries and mucocutaneous exposure incidents.”
Centers for Disease Control and Prevention (CDC). Chapter 7: Management of Potentially Infectious Exposures and Illnesses. In: Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services (2019). Available at: https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/exposures.html
CDC. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. Available at: https://www.cdc.gov/hicpac/recommendations/core-practices.html
International Safety Center. Improving Work Wear for Workers at Risk of Exposure to Blood, Body Fluids, and Other Biologic Hazards: A Consensus Statement and Call to Action. March 2017. Available at: https://internationalsafetycenter.org/wp-content/uploads/2017/04/Consensus-Statement-Improving-Work-Wear-for-Healthcare.pdf
Occupational Safety and Health Administration (OSHA). Standard 1910.1030 - Bloodborne pathogens. Available at: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030
World Health Organization (WHO). Occupational Infections. Available at: https://www.who.int/tools/occupational-hazards-in-health-sector/occupational-infections