At a time when universal health coverage is an overriding goal for sustainable development, the well-being of health care workers must be prioritized. They are the indispensable life-savers in the health care equation. Without a sufficiently staffed, healthy, and protected workforce, can UHC be achieved?
Safety First explores the challenges of needlestick and sharps safety and highlights efforts to ensure patient and health care worker safety around the world. Join the conversation using #HCWSafety and #PatientSafety.
For as long as we can trace, it has been the place of the medical provider to assume responsibility for the safety of patients in their care. Despite the peril inherent in providing care to the ill, there was no view that providers were entitled to protection of their own health and lives.
The change that finally occurred in the late 1980s was not a timid one. The advent of the HIV/AIDS pandemic and the first reports that identified caring for HIV/AIDS patients as a risk factor for contracting HIV led to palpable panic and pressure, applied by professional associations and unions, to engage policymakers with influence in health care settings.
Nothing short of a revolution swept through the medical device industry, resulting in the replacement of the most common and frequently used medical devices with an array of products reengineered for the single purpose of protecting health care personnel from injury and transmission of infectious pathogens.
In 2000, influential agencies, such as the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration, among others, were key actors in achieving change by introducing policies to protect health care workers from blood exposure.
A movement that came out of a tragedy
How cross-sector engagement helped effect change
Medical device manufacturers adopted safety engineering of sharp instruments as a top priority and, alongside health care worker advocates, assumed a role at the forefront of both engineering and policy change. When the new generations of safety-engineered devices were widely available, surveillance data and product evaluations confirmed their effectiveness in preventing injuries. As early as 1990, the industry invested in developing devices with sharps injury prevention features, as well as continuing education accredited programs to raise awareness of the risks of sharps injuries and the need for engineering control.
Academics also developed new surveillance and reporting systems, enabling hospitals to precisely identify and track the sources of sharp object injury — in turn facilitating injury prevention strategies, including the use of safety-engineered devices in routine clinical practice.
This advocacy and leadership continued in the push to pass the Needlestick Safety and Prevention Act of 2000, signed into law in the U.S. by former President Bill Clinton, to amend OSHA’s Bloodborne Pathogens Standard. The aim was to strengthen the requirement for health care employers to provide safety-engineered devices to workers.
Renewed mobilization of health care worker training efforts followed this, to support the transition from conventional to safety-engineered devices. For example, BD deployed over 600 trainers to provide training on the use of safety-engineered devices in hospitals throughout the U.S.
The top transmission route was identified to be injuries from needles or sharp instruments contaminated with blood from HIV positive patients, hence the focus on injury reduction from sharp medical devices as a primary prevention strategy. There were numerous factors that needed to be in sync to bring about this revolution.
The first of these, which everything else depended upon, was the engagement of the medical device manufacturers and their willingness to reengineer a host of the most commonly used devices, such as syringes and sharp surgical instruments, with safety features including protective shields for needles, and even eliminating the use of needles when possible.
Companies were being asked to “cannibalize” their own products, which in many cases was their core business. But instead of pushback from the manufacturers, there was a push forward.
Based on the mobilization to address sharp object injuries, and policy changes that facilitated adoption of safety designs in the United States and Western Europe, transition to these devices has occurred at a large scale. However, these achievements have fallen short in places where they are most needed: in low- and middle-income countries such as those in sub-Saharan Africa where the prevalence of HIV/AIDS and other bloodborne infections remains high.
Moving the needle in LMICs
Efforts are continuing to prompt larger scale transition to safety devices in LMICs. However, several factors have inhibited the transition to safety devices in these countries, despite substantial efforts to mobilize the same type of changes that have occurred in other regions.
Significant change is only likely to be seen when governments in LMICs enact the types of laws, regulations and guidelines that are needed to achieve transition at large scale. The following key factors will help drive transition and change with the ultimate goal of policy alignment:
Tackle stigma. Despite efforts to deploy surveillance systems to collect data on the incidence of sharp object injuries in LMICs, there is still significant stigma associated with reporting needlestick injuries in some countries, and so underreporting is a major challenge. What data is collected often has not been widely communicated or shared. It is necessary to reduce stigma in order to ensure sharps injuries are no longer overlooked.
Promote advocacy. Increase the opportunity for health workers, particularly nurses, to influence change. Some of the most vocal advocates for policy change in the U.S. were affected health care workers telling their stories.
Reframe the cost conversation. Safety-engineered needle devices cost more to manufacture than conventional needle devices, and therefore are more expensive to procure, though the gap between conventional and safety devices has reduced over time. However, the costs of complications, treatment, and loss of productivity due to needlestick injuries are not fully contemplated in this type of procurement decision.
The road ahead
The Ebola epidemic in West Africa in 2014 and the more recent resurgence of the disease underscores how important health care worker safety remains. It is estimated that two-thirds of health care workers who contracted Ebola due to exposure to infected patients in the three affected countries in 2014 — Liberia, Guinea, Sierra Leone — died as a result.
Safety-engineered needle devices for blood drawing and IV infusions were needed to protect health care workers from exposure to Ebola. In fact, BD donated devices valued at over $1 million in order to help protect health care workers.
In 2015, the World Health Organization issued new guidelines on injection safety. While WHO guidelines are taken very seriously in LMICs, movement to concrete policy and practice change at country level has been slow. Additionally, these guidelines only covered syringe and needle usage and did not cover devices such as blood drawing needles that are more likely to transmit infectious diseases from patient to health care worker.
Despite these additional barriers, efforts are continuing to achieve broader transition to safety devices in LMICs. Manufacturers are collaborating with leading public health agencies such as CDC to train health care workers in LMICs on safer sharps practices; new lower cost safety devices have been developed; and there is an ongoing effort to raise awareness of the need to protect health care workers from sharp object injuries.
Having a strong and vibrant health workforce is critical to keeping patients and communities safe and is essential to achieving UHC and fulfilling the Sustainable Development Goals. The tools and examples to promote health care worker safety are available, and we can no longer tolerate a trade-off of health care worker risk for the sake of patient care.
We should instead focus on driving a “safety first” approach for patients and practitioners.