Needlestick prevention bill includes new workplace rules

Washington -- Each year 600,000 to 800,000 health care workers, including many physicians, are accidentally stuck by contaminated needles or other sharp objects. A bill that recently passed Congress aims to reduce that number.

The measure requires employers, such as hospitals and physician groups, to study and implement the use of medical devices with safety features in their facilities and offices where appropriate, effective and available. They must document annual evaluation and adoption of safer medical devices, such as needleless systems or equipment with "sharps injury protections."

Physicians are second only to nurses in the ranks of health care workers injured by needles and other sharp objects. These wounds put physicians and other health care workers at risk of HIV and hepatitis B and C infection.

Resident physicians are at particularly high risk for exposure to patients' blood or body fluids through punctures or splashes, said Emilie Osborn, MD, a family physician at the Palo Alto Medical Foundation in California. "There is pressure to do things and act as though they know how to do things that they don't know how to do, "said Dr. Osborn, who authored a study on the subject published last year.

Although some hospitals are models of health care worker safety, "most are not complying or complying marginally" with federal rules designed to reduce needlesticks, said June Fisher, MD, associate clinical professor of medicine at the University of California at San Francisco.

"At private physician offices, they either don't know anything about [occupational safety] or they want to ignore it," she said.

The legislation, expected to be signed by President Clinton, builds on and strengthens a directive the Occupational Safety and Health Administration issued to its inspectors in November 1999. It requires employers in the health care field to include frontline workers, such as physicians and nurses, in the selection of safer devices.

This requirement is "vital," said Samuel Hughes, MD, professor of clinical anesthesia at the University of California at San Francisco.

"Those people are able to judge what equipment will work and be safer," said Dr. Hughes, who chairs an infection control task force for the American Society of Anesthesiologists' occupational health panel.

This input also is necessary to ensure that physicians and others use the new, safer equipment, said Jane Perry, spokeswoman for the International Health Care Worker Safety Center at the University of Virginia Health System. "Unless you get health care worker buy-in, you can get all the safety devices you want, but health care workers won't use them. They'll just sit on the shelf."

The bill, sponsored by Rep. Cass Ballenger (R, N.C.) and Sen. Jim Jeffords (R, Vt.), also requires health care employers to keep a log of all injuries caused by needles or other sharp equipment. This provision applies only to employers with more than 20 workers.

The log must include the type and brand of device involved in the incident,the work area where the exposure occurred, and an explanation of how the injury happened. The goal is to identify patterns to determine which work areas have a high risk of exposure; where new, safer devices might be needed; and where employee training might be necessary.

Physicians have some concerns about how the bill might be implemented if it becomes law.

For example, it is important that physicians and other health care workers be allowed to choose between the old versions of devices and the new, safer ones, Dr. Hughes said. In some cases, the older device might be better for the patient, he added.

Dr. Hughes gave the example of when a physician must administer a difficult, emergency IV. The old, familiar equipment might be easier and quicker to use than new, safer technology, he said.

Physicians and safety experts also note that the legislation alone will not eliminate needlesticks.

"Safe needles are an improvement, but they don't make up for [inadequate] training or bad technique," said J. Chris Hawk III, MD, a member of the AMA Council on Scientific Affairs.

Many physicians believe that devices that enhance health care worker safety interfere with patient care, Dr. Fisher said -- a view that stems from a lack of training.

Some physicians and safety experts worry that more education needs to be done to bring physicians up to speed on safety technology, existing OSHA rules and the new requirements the bill would create.

Dr. Fisher argues that self-retracting devices that make injections and blood withdrawal safer already exist and can be used effectively and without much added cost in physician offices. But many physicians aren't familiar with the technology, she said.

Medical societies and the federal government have not done enough to inform physicians of federal requirements, Dr. Hawk said. "Doctors don't read the Federal Register," he added.

Physicians in small practices are likely to view the new rules as "an additional burden," said Bruce Bagley, MD, chair of the American Academy of Family Physicians. However, he added, "if it's truly an improvement, then most physicians would want to do it."

Workers at risk

Hundreds of thousands of health care workers are exposed to patients' blood or body fluids each year, putting them at risk for contracting HIV and hepatitis. Most exposures in hospitals result from punctures by needles or other sharp objects:

Needle or sharp object 83%

Mucous membrane 13%

Skin 3%

Bite 1%

Chances of injury are high

Only nurses are more likely than physicians to be exposed to patients' blood or body fluids in hospitals. Of those exposed:

Nurses 44%

Physicians 30%

Technicians 13%

Housekeeping/maintenance 3%

Students 3%

Clerical/administrative staff 1%

Researchers 1%

Dental 1%

Others 4%

Source: National Surveillance System for Hospital and Health Care

Workers