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Federal Document Clearing House
Congressional Testimony
June 22, 2000, Thursday
SECTION: CAPITOL HILL HEARING TESTIMONY
LENGTH: 3174 words
HEADLINE:
TESTIMONY June 22, 2000 ENID K. ECK, RN, MPH SENIOR CONSULTANT, HIV AND
INFECTIOUS DISEASE KAISER PERMANENTE HOUSE EDUCATION AND THE
WORKFORCE OSHA NEEDLESTICK INJURY COMPLIANCE DIRECTIVE
BODY:
SUBCOMMITTEE ON WORKFORCE PROTECTION
Committee on Education and the Workforce "OSHA Compliance Directive on
Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens"
Enid K. Eck, RN, MPH Senior Consultant, HIV and Infectious Disease, Kaiser
Permanente, California Background: Kaiser Permanente has an extensive history of
supporting a wide range of initiatives that enhance patient and health care
worker safety. Over the past several years concern about occupationally acquired
infections has increased with a particular focus on infections that may be
transmitted through infected blood or body fluids. Kaiser Permanente provided
leadership and significant support to the recent California legislative and
regulatory requirements that address blood borne pathogens and the use of work
practice, administrative and engineering controls to reduce the risk for
exposure to such diseases. We have also supported similar legislation in other
states and at the federal level. Through the oversight and coordination of the
Sharps Safety Committee that I have chaired for several years, Kaiser Permanente
has been implementing sharps safety devices while assuring patient safety since
1991, long before it was mandated by any legislation. We have learned some
important lessons along the way and I am grateful for this opportunity to share
our experience as we did throughout the recent process in California. That
process was very collaborative, including representatives from labor, the state
legislature, the healthcare industry, device manufacturers, and the public. The
net outcome was the development of requirements that effectively address the
various competing interests and issues. To effectively facilitate
implementation, it is our position that all such legislation should explicitly
incorporate specific requirements that address such essential elements as: 1)
patient safety assurance, 2) use of sharps injury log data to evaluate and act
on product efficacy, 3) reasonable flexibility that permits clinicians to
utilize appropriate clinical judgment, 4) promoting technology development.
Patient Safety Assurance: Although needles and syringes are the primary device
that people tend to think of as posing the greatest risk to health care workers,
the delivery of health care involves the use of thousands (1000 s) of devices
that are capable of causing a puncture or cutting injury that could lead to a
blood or body fluid exposure. Current sharps safety technology does not exist
for all of the devices that can cause sharp injuries and in many cases the
safety alternatives are only available in limited sizes or gauges. Without
specific legislative language that assures the importance of patient safety,
health care workers are placed in the untenable position of trying to use
currently available technology in ways that reduce patient safety or impair
basic health care delivery. For example, a diabetic patient learning to do home
blood sugar monitoring must be taught on the equipment that s/he will use at
home. At present, safety alternatives are not available for such devices. Health
care professionals teaching patients the correct procedure to use at home must
choose to use a safety device which will not be used at the patient's home or
teach the patient with the correct home care product and not comply with sharps
safety legislation. This leads to confusion in the patient education process and
potential increased risks to the patient who is learning an important skill for
home care. As technology improves and market availability stabilizes the current
limitations will diminish, however patient safety must not be compromised in the
interim. Use sharps injury log data to evaluate and act on product efficacy:
Pursuant to 29CFR 1904.2 the OSHA 200 log must contain certain personal
identifying information including the employee's full name and an identification
number (e.g. social security number). Health care workers concerned about
privacy protection may avoid reporting sharps injuries out of concern that
medical record confidentiality will be breached. The establishment of a sharps
injury log as described in the Cal-OSHA Standard has created a better data base
from which to guide all sharps injury reduction efforts because it includes very
useful information that is not contained in the OSHA 200 Log and excludes
information that is perceived as a barrier to reporting injuries. Additionally,
because the OSHA 200 Log summary must be conspicuously displayed annually (per
29CFR 1904.5) in an area that is readily accessible for other workers to review,
this may heighten the employee's perception that sensitive information may not
be adequately protected through the existing OSHA 200 process. Research has
already demonstrated a potential for significant underreporting of sharps
injuries and any additional perceived barriers or risk of decreased anonymity
may only make underreporting worse, thereby reducing our ability to facilitate
injury reduction through better product selection, improved work practices and
administrative controls. The Sharps Injury Log, required in the Cal-OSHA
standard, specifically excludes personal identifying information and focuses on
the specific sharps injury, its cause, contributing factors and potential
mechanisms for prevention. Health Care Workers are therefore encouraged to
report any sharps injury, seek testing and appropriate treatment and help to
contribute to further injury reduction by sharing ideas they may have on further
prevention. A comprehensive sharps injury log also assures that employers can
determine if the safety devices they provide to workers are effectively reducing
injuries. Some sharps safety devices have had virtually no impact on injury
reduction and others have lead to increases in injuries due to their engineering
design. Employers must be provided with the option to include alternative work
practices or administrative controls in the event that a particular sharps
safety device is not effective in reducing injuries. Although virtually any
contaminated sharps/needle device may pose some risk for disease transmission,
extensive research has demonstrated that large hollow-bore devices used for
drawing blood or establishing access to a vein or artery pose the greatest risk
for disease transmission. Legislation that encourages employers to focus their
efforts on these higher risk devices would be extremely beneficial, especially
as the device market changes and technology continues to improve. Reasonable
flexibility that permits clinicians to utilize appropriate clinical judgment:
Over the past several years it has become clear that, in addition to the
limitations inherent in current safety technology and the engineering features
of many devices, there are patient specific issues or procedures that may
preclude the use of selected safety devices. Elderly patients with particularly
fragile veins may not be good candidates for devices that mechanically retract
outside the control of the clinician. Extremely small premature infants may have
conditions that prohibit the use of devices that have particular types of
engineering controls or larger sizes of specific safety devices when the
smaller, more appropriate device doesn't have a safety design. These situations
are limited but part of real world medical practice and our most vulnerable
patients may be put at increased risk if clinicians are not permitted to utilize
their expert clinical judgment in selecting the most appropriate sharps/needle
device. The correct balance of patient safety and health care worker safety can
be assured if the health care worker, directly involved in providing patient
care, is empowered to exercise appropriate clinical judgment in such limited
cases. Technology development Needles/sharps with engineered safety protection
are relatively new devices. Market forces will continue to facilitate the
development of better devices that work more effectively and address a wider
range of patient care related needs. Any legislative language that restricts or
hampers the free market, competitive development of improved technology would be
detrimental to the goal of injury reduction. Therefore, the less restrictive
and/or specific that legislative language is regarding the description of the
type of safety design or engineering control the better. If manufacturers
interpret language as restricted to specific design types (e.g. sheathing,
blunting, retracting, etc.) then the breakthrough technology that is truly
needed will be slow in coming. We believe that the more generic description
included in the Cal- OSHA Standard (e.g. needles/sharps with built in engineered
safety protection) is more likely to facilitate innovative manufacturing and
encourage development of the most appropriate technology. Conclusion: Preventing
sharp and needle related injuries that lead to bloodborne pathogen infections is
essential, it is however a very complicated challenge with no simple solution.
Because of the complex, ever changing nature of healthcare delivery it is
essential that legislation be directed toward resolving the problem of sharp
injury associated infections without increasing the barriers to either injury
reporting or patient care. We believe that the language in the Cal-OSHA
Bloodborne Pathogen Standard effectively addressed these issues. The specific
language outlined in the "exceptions" section of the Standard was developed
after extensive dialog with all the interested parties and serves as a model for
this current process. Legislation that assures patient safety, comprehensive
injury surveillance, encourages appropriate clinical judgment and provides
incentives to technology development will serve to protect the public and our
valued healthcare workforce.
LOAD-DATE: July 3, 2000,
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