Infection Special Book: Control, Prevention, BBP, SARS, FluPage 18 of 46

3. Engineering Controls

Nurse Jennifer completed the incident report with her Charge Nurse and immediately was sent to the lab for a blood draw and rapid HIV test. She received her HBV series five years ago when she began nursing school. Was she still covered against HBV? What is the blood test for HIV? How soon does HIV testing show results? Jennifer suffered emotionally throughout the rest of her shift until the answers came. Was she wearing gloves when she took the blood specimen? Didn’t she always? Now she couldn’t remember because she wasn’t consistent about PPE use.

Engineering controls are devices that isolate or remove the bloodborne pathogen hazard from the workplace (OSHA, 2019a). Controlling the environmental hazards are part of the directive to decrease the potential for the spread of bloodborne pathogens and other potentially infectious agents. The various environmental controls include:

  • Hand washing, that sends pathogens on the worker’s hands down the drain and out of the workplace
  • Elimination of hazardous materials from the workplace, such as the replacement of a hazardous chemical with a safer one, or needleless systems for injection
  • Devices that contain the hazard, such as specimen containers, safety sharps, sharps disposal containers, and red bags

Engineering controls, including facilities for hand washing, must be maintained or replaced on a regular schedule to ensure their effectiveness. When handwashing facilities are not available, an antiseptic hand cleanser should be provided. Hands must be washed after gloves are removed or any time there is skin contact with blood or other body fluids.

Specimen containers should not leak. If there is a possibility of leakage a secondary container must be used. All containers with dirty particles such as laundry and garbage must be placed in a soiled utility room away from clean supplies and laundry.

Safety When Handling Sharps

The federal OSHA Bloodborne Pathogens Standard was amended in 2001 to add the provisions of the Needlestick Safety and Prevention Act of 2001 (public law 106-430). Since then, safety syringes are required for use whenever possible in healthcare facilities. This legislation mandates that institutions conduct annual product reviews of sharps safety devices and that non-managerial employees be involved in the decision-making process.

An estimated 800,000 needle sticks and other sharps injuries are reported each year, but the CDC believes that even more such injuries go unreported. Researchers at Johns Hopkins University reported that nearly 60% of medical school graduates surveyed had been stuck by a needle during medical school but half of them did not report the injury to hospital officials. The primary reason for not reporting was the amount of time and paperwork involved in making a report. Those surveyed had trained to become surgeons at seventeen medical centers in the United States (Sharma et al., 2009, Quinn et al., 2009).

Other reasons for not reporting sharps injuries include the lack of a clear policy and process for reporting the injury, lack of available PPEs and disposal containers, insufficiently trained staff, shortage of staff, and perceived retribution, or complication of completing and filing an incident report (Braun, n.d.). Recognizing the barriers to reporting needle sticks is important before facility administrators can strategize how to improve the process. Competing an incident report has often triggered reprimand, yet the report should be used as a tool for improvement rather than punishment.

Two-thirds of nurses report being accidentally stuck by a needle while working, and three-fourths of them were contaminated needle sticks. Although the overwhelming majority of nurses knew the workplace protocol concerning needle stick injuries, only 7 out of 10 reported the incident (Firas et al., 2014).

Care must be used whenever handling sharps, especially contaminated sharps. Needle sticks and other sharps injuries carry extra risk of exposure since they penetrate the protection of intact skin.

The best way to prevent cuts and sticks is to minimize contact with sharps. That means:

  • Not using a sharp when an alternative method is available
  • Activating safety sharps immediately following completion of use
  • Disposing of used sharps immediately

A needle stick or a cut from a contaminated scalpel can lead to infection by one of the bloodborne viruses. Risk of infection varies by which pathogen is involved.

Puncture-resistant containers must be available nearby to hold contaminated sharps. When reusable sharps must be used, puncture-resistant transport containers must not require employees to reach into the holding container. Newer sharps containers allow the nurse or healthcare professional using the sharp to simply drop it into the top of the container rather than forcing it into a side flap where other needles may be sticking out and potentially cutting the intruding hand.

Recapping, bending, or removing needles should not be done unless there is no feasible alternative or if required for a specific medical procedure. If recapping, bending, or removal is necessary, workers must use either a mechanical device or a one-handed technique. If recapping is required, a one-handed "scoop" technique may be used, using the needle itself to pick up the cap, pushing cap and sharp together against a hard surface to ensure a tight fit.

There has been considerable media attention about disease outbreaks caused by unsafe injection practices. The CDC has reported nearly 50 outbreaks linked to unsafe injection practices, with more than 150,000 patients affected since 2001. These outbreaks have included transmission of hepatitis B and C as well as bacterial infections (CDC, 2016).

Syringes and needles must be used for only one patient in every circumstance. This is a matter of protecting patients from diseases spread by injection.

Sharps Containers

Containers of used sharps are regulated waste and must be handled as specified in the Standard. They must be puncture-resistant, closable, and the sides and the bottom must be leakproof. They must be labeled or color-coded red to ensure that everyone knows the contents are hazardous. Containers for disposable sharps must be easily accessible and they must be maintained upright to keep liquids and sharps inside.

Containers need to be located as near as feasible to the area of use. In some cases, they may be placed on carts to prevent access by mentally disturbed or pediatric patients. Containers should also be available wherever sharps may be found, such as in public bathrooms for insulin pens and facility laundries. The containers must be replaced routinely and not be overfilled. Many facilities have added a specific policy to replace the container when it is three-quarters full rather than waiting until it is completely full.

Employees must never reach into containers of contaminated sharps. Containers for reusable sharps could be equipped with wire basket liners for easy removal during reprocessing, or employees could use tongs or forceps to withdraw the contents. Reusable sharps disposal containers may not be opened, emptied, or cleaned manually.

Employees should use caution when handling full containers of used sharps, looking carefully for needles that may have punctured the container. Lids should be closed before discard and transportation. If there is a chance of leakage from the primary container, a secondary container that is closable, labeled, or color coded and leak resistant should be used.

Test Your Knowledge

Employees do not need to wash hands when gloves have been used to handle items contaminated with blood or body fluids.

  1. True
  2. False

Needles or contaminated sharps should:

  1. Be disposed of immediately after use into puncture-resistant containers.
  2. Always be recapped after use to prevent a needle stick.
  3. Always be recapped using both hands if recapping is essential.
  4. Be bent and broken prior to disposal to prevent needle sticks.

To decrease chance of contracting bloodborne illness:

  1. Only employees trained to empty sharps containers are allowed to reach into the containers.
  2. Because sharps containers must be replaced when filled to the top the lids should not be closed.
  3. Employees must never reach by hand into containers of contaminated sharps.
  4. Sharps containers should be opened, emptied, and cleaned manually.

Apply Your Knowledge

What is your facility’s policy should you get a needle stick? What is the policy for replacing and emptying sharps containers? If you have been stuck before with a needle what could you or the facility have done to avoid it?

Answers: B,A,C