Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program

Contents:

ORGANIZATIONAL STEPS

This section describes a series of organizational steps that are designed to ensure that a sharps injury prevention program:

• Is integrated into existing safety programs,
• Reflects the current status of an institution's prevention activities, and
• Targets appropriate areas for performance improvement.

Processes Performance Improvement

Although the program focuses on preventing sharps injuries, it is based on principles that can be applied to the prevention of all types of blood exposures.

Step 1. Develop Organizational Capacity

The proposed model is an institution-wide program (i.e., encompassing all aspects of an organization, whether a small private practice or a complex medical center) in which responsibility is held jointly by members of a multidisciplinary leadership team that is focused on eliminating sharps injuries to healthcare personnel. Representation of staff from across disciplines ensures that needed resources, expertise, and perspectives are involved. The responsibility and authority for program coordination should be assigned to an individual with appropriate organizational and leadership skills. Representation from senior-level management is important to provide visible leadership and demonstrate the administration's commitment to the program. The team should also include persons from clinical and laboratory services who use sharp devices, as well as staff with expertise in infection control, occupational health/industrial hygiene, inservice training or staff development, environmental services, central service, materials management, and quality/risk management, as available. Regardless of the type or size of the organization, a multidisciplinary approach is essential to identify health and safety issues, analyze trends, implement interventions, evaluate outcomes, and make recommendations to other organizational components.

Model for a Leadership Team

Although the leadership team should include a small core group of clinical staff, other staff from areas such as radiology, anesthesiology, respiratory therapy, surgery, hemodialysis, intensive care, pediatrics, and other units might be invited to participate in a particular discussion or as part of an ad hoc subcommittee.

In this first step, the leadership team should outline how it plans to achieve the goal of injury reduction or elimination. The team should determine which of the facility's standing committees will contribute to the process and how these committee's will exchange information. Committees might include:

• Infection Control
• Quality Improvement
• Occupational Health and Safety
• Value Analysis
• Materials Management/Product Evaluation

In some organizations, one of these committees might be charged with oversight of the sharps injury prevention program. However, each committee should become involved in designing the sharps injury prevention program. For example, the Occupational Safety and Health or Infection Control committees might provide monthly reports on sharps injuries. In turn, the leadership team might work with the Occupational Safety and Health or Infection Control committees to improve the quality of information collected to better meet performance improvement goals.

Step 2. Assess Program Operation Processes

The proposed program model includes five operational processes, each of which is discussed in detail in subsequent sections of the workbook. These include:

1. Institutionalize a culture of safety in the work environment,
2. Implement procedures for reporting and examining sharps injuries and injury hazards,
3. Analyze sharps injury data for prevention planning and measuring performance improvement,
4. Selection of sharps injury prevention devices (e.g., devices with safety features), and
5. Education and training of healthcare personnel on sharps injury prevention.

The team should conduct a baseline assessment of each of these processes to determine where improvements are needed.

Toolkit Resource for This Activity:

Baseline Program Assessment Worksheet (see Appendix A-1)

Assessing the Culture of Safety

This assessment determines how safety, particularly sharps injury prevention, is valued in the organization and what processes are in place to promote a safe work environment for the protection of patients and healthcare personnel. Key elements of an organizational safety culture and suggestions for improving safety awareness are discussed in Operational Processes, Institutionalize a Culture of Safety in the Work Environment. As part of a baseline assessment, the team should assess the following:

• Organization leadership's commitment to safety;
• Strategies used to report injuries and to identify and remove injury hazards;
• Feedback systems to improve safety awareness; and
• Methods to promote individual accountability for safety.

The team should also explore the data sources (e.g., written or observational surveys, incident reports) that are used or could be used to measure safety culture performance improvement. As part of the baseline assessment and as a possible mechanism for measuring performance improvement, the team might consider using the following tool to survey staff about their perceptions of a safety culture in the organization.

Toolkit Resource for This Activity:

Survey to Measure Healthcare Personnel's Perceptions of a Culture of Safety (see Appendix A-2)

Assessing Procedures for Sharps Injury Reporting

Most healthcare organizations have procedures for reporting and documenting employee needlesticks and other percutaneous injuries. The team should assess whether these procedures are adequate for data collection and analysis and determine the data sources that can be used to assess improvements in injury reporting.

As part of the baseline assessment, the team should consider using the following tool to assess the completeness of sharps injury reporting. (Although postexposure management is not included in the model for a sharps injury prevention program, the survey tool does include questions that can be used to assess worker satisfaction with the postexposure management process.) Periodic repeat surveys (e.g., every few years) can be used to measure improvements in reporting compliance.

Toolkit Resource for This Activity:

Survey of Healthcare Personnel on Occupational Exposure to Blood and Body Fluids (see Appendix A-3)

Assessing Methods for the Analysis and Use of Sharps Injury Data

Data on sharps injuries need to be analyzed and interpreted so it will be meaningful for prevention planning. This part of the assessment determines how these data are compiled and used in the organization. See Operational Processes, Analyze Sharps Injury Data, for a discussion of how to perform simple data analysis.

Assessing the Process for Identifying, Selecting, and Implementing Engineered Sharps Injury Prevention Devices

Because an important goal of this workbook is to provide information and guidance on the implementation of devices with engineered sharps injury prevention features, a model approach for the evaluation of these devices is included in Operational Processes, Selection of Sharps Injury Prevention Devices. This baseline assessment considers who is involved and how decisions are made. As with other program functions, it is important to determine the data sources (e.g., product evaluation committee reports, lists of manufacturers contacted, device lists) that can be used to measure process improvement. A similar process assessment of methods for identifying and implementing other prevention interventions (e.g., changes in work practices, policies, and procedures) also could be included in this baseline assessment.

Assessing Programs for the Education and Training of Healthcare Personnel on Sharps Injury Prevention

Most healthcare institutions have a plan for providing employee education and training on bloodborne pathogen prevention at the time of hire, as well as on an annual basis. The implementation of a sharps injury prevention program is an opportune time to reassess the quality of these efforts and to identify other education and  training opportunities. As with other processes, it is necessary to identify the data (e.g., staff development reports, curriculum changes, training) that can be used to assess improvements in educating and training healthcare personnel.

Step 3. Prepare a Baseline Profile of Sharps Injuries and Prevention Activities

After assessing program operations, the next step is to develop a baseline profile of injury risks in the institution. This information, along with the information gleaned from the baseline assessment, will be used to develop an intervention action plan.

Toolkit Resource for This Activity:

Baseline Institutional Injury Profile Worksheet (see Appendix A-4)

Toolkit Resource for This Activity:

Baseline Injury Prevention Activities Worksheet (see Appendix A-5)

Using data currently available in the organization and the tools provided in this workbook, develop a profile of how injuries are occurring and a list of current prevention strategies. The following questions may help guide the development of this profile, but other questions may be added.

• What occupational groups most frequently sustain sharps injuries?
• Where do sharps injuries most frequently occur?
• What devices are most commonly involved in sharps injuries?
• What circumstances or procedures contribute to sharps injuries?
• What sharps injuries pose an increased risk for bloodborne virus transmission?
• Has the organization taken steps to limit the unnecessary use of needles by healthcare personnel? If so, how has this been done?
• What devices with engineered sharps injury prevention features have been implemented?
• Is there a list of recommended work practices to prevent sharps injuries?
• What communication tools have been used to promote safe sharps handling techniques?
• Is there a policy/procedure for determining the appropriate location of sharps containers?
• Who is responsible for removing/replacing sharps containers?

Step 4.     Determine Intervention Priorities

Not all problems can be addressed at once, so healthcare organizations must decide which sharps injury problems should receive priority attention. Baseline information on sharps injuries, along with the weaknesses identified in the assessment of program operation processes, should be used to determine priority areas.

Sharps Injury Prevention Priorities

The following approaches can be used alone or in combination to create a list of initial priorities for intervention:

• Determine priorities based on injuries that pose the greatest risk for bloodborne virus transmission (e.g., focus initially on preventing injuries associated with vascular access)
• Determine priorities based on the frequency of injury with a particular device (e.g., focus on injuries associated with hypodermic or suture needles)
• Determine priorities based on a specific problem contributing to a high frequency of injuries (e.g., focus on sharps handling and/or disposal)

Toolkit Resource for This Activity:

Same as for Step 3

Program Process Improvement Priorities

Leadership teams might consider selecting one problem in each of the processes or focus only on one of the processes for performance improvement. Give priority to those areas that will have the greatest impact on improving the overall operation of the program.

Step 5. Develop and Implement Action Plans

An intervention action plan provides a road map for charting the course, monitoring progress, and measuring performance improvements in a sharps injury prevention program. Two intervention action plans are proposed:

• The first focuses on implementing and measuring interventions to reduce specific types of injuries.
• The second measures improvements that are the result of the program processes.

Action Plan to Reduce Injuries

Set Targets for Injury Reduction. Based on the list of priorities, set targets for reducing specific types of injuries over a designated period (e.g., six months, one year). These targets should provide reasonable expectations based on the interventions available and the degree to which they are likely to be successful.

Specify Interventions. For each problem targeted for intervention, apply one or more of the following strategies:

• Substitute a non-sharp alternative for performing a procedure
• Implement a device with an engineered sharps injury prevention feature
• Recommend a change in work practice
• Change a policy or procedure
• Provide targeted education of healthcare personnel

The intervention action plan should reflect each strategy used and describe the steps, time line, and responsibility for implementation.

Identify Indicators of Performance Improvement. Indicators are tools for measuring progress; they tell when a goal is reached. The following can be used to measure the impact of an intervention on injuries:

• Changes in the frequency of certain types of injuries
• Frequency of compliance with the use of a newly implemented engineering control
• Changes in injury rates, e.g., device-specific or occupational

Once the indicators are identified, the team will need to decide:

• How frequently indicators will be monitored (e.g., monthly, quarterly, semiannually, annually), and
• How and by whom they will be reported.

Toolkit Resource for This Activity:

Sharps Injury Prevention Program Action Plan Forms (see Appendix A-6)

Action Plan to Measure Program Performance Improvement

The baseline profile will identify the strengths and weaknesses of the organization's sharps injury prevention activities. With this information, the team can create a list of priorities for performance improvement and then decide how to accomplish the necessary tasks. When writing this part of the action plan, the team should be sure that the areas for process improvement are clear and measurable. To increase the likelihood of success, only a few improvements should be taken on at a time.

Step 6. Monitor Program Performance

The one questions asked repeatedly during the assessment of operational processes is: What data can be used to measure performance improvement for each process? Once identified, data from each of these processes should be used to monitor overall program performance. In addition, as with any planning function, a checklist of activities and a timeline for implementation should be developed to monitor progress. The team should consider developing a monthly or quarterly schedule for reviewing performance improvement. Not all areas targeted for improvement need to be reviewed at each team meeting. By spreading these over the year, the team can spend more time on each issue. If the desired objectives are not being met, the team should redesign the plan accordingly.

The process of designing, implementing, and evaluating a sharps injury prevention program is continuous. At least once a year, the team should reassess the processes for avoiding injuries.