February 2000 Bulletin

A needlestick injury and other sharps-related injuries could change the life of an orthopaedic surgeon forever if the physician is exposed to bloodborne pathogens, such as HIV, hepatitis B virus (HBV), hepatitis C virus (HCV).

According to the federal Occupational Safety and Health Administration (OSHA) estimates, 5.6 million workers in the health care industry and related professions are occupationally exposed to these bloodborne pathogens.

The National Institute for Occupational Safety and Health (NIOSH) estimates that nearly 600,000 needlestick injuries accidentally occur yearly in a hospital setting, with nurses mostly at risk. The agency says the exact number of injuries is not known due to the underreporting of incidents. Bloodborne infections via needlesticks is often asymptomatic until weeks or months after the injury.

"Although orthopaedists rarely use needles, they can end up being stuck with needles either lying around in a minor bedside procedure or in a major or minor surgical procedure in the OR," says David W. Florence, MD, chairman of the Academy’s occupational health committee. "Some needles also are used with certain procedures such as in aspirations, injections, etc. There’s also a risk of cuts and sticks from scalpels, drills, bone fragments and anything sharp that passes through the skin."

In an effort to protect and prevent health care workers from occupational exposure to needle stick injuries, federal and state legislation has been introduced. The "Health Care Worker Needlestick Prevention Act," was introduced in the United States Senate (S.1140) and House (H.R. 1899); both bills are in committee. Legislation on needlestick prevention and healthcare worker protection has also been enacted in California, Tennessee, Maryland, Texas and New Jersey. Sixteen other states introduced bills in 1999, with more states expected to follow this year.

OSHA issued a compliance directive on Nov. 5, 1999 that updates the agency’s 1992 bloodborne pathogens compliance instruction. The new directive guides OSHA’s compliance officers in enforcing OSHA’s bloodborne pathogens standard first issued in 1991.

According to Melody Sands, director of OSHA’s office of health compliance assistance, the new directive "emphasizes the importance of the annual review of the exposure control plan and the use of engineering controls such as safe needle devices, including needleless IV systems, retractable or self-blunting needles and safety sheaths. If health care and other facilities are not using engineering controls to eliminate or minimize exposures, a violation may exist and we could issue a citation."

Part of the directive to compliance officers notes, "physicians who are unincorporated sole proprietors or partners in a bona fide partnership are employers and may be cited if they employ at least one employee, such as a technician or secretary."

"OSHA is not doing any programmed inspections at this time," says Sands. "All of our inspections presently are generated as a result of employee complaints."

Yet, many needlesticks have gone unreported, admits Sands. "A real problem with our current record-keeping guidelines is employers don’t have to report a needlestick unless it results in HCV, HBC or HIV," she says. "OSHA is looking to change that requirement by the summer of 2000 and make all needlestick injuries recordable. "It [reporting mechanism] will become effective Jan. 2001," she says.

Since 1991, safer medical devices have become more available. Currently, the U.S. Food and Drug Administration (FDA) has approved about 50 specially protected needles and syringes and numerous other devices on the market. OSHA does not advocate the use of any particular safer needle. "We’re just saying, ‘We know there’s lots of safer needle devices out there; take your pick–but use something,’" says Sands.

On the heels of OSHA’s directive came the NIOSH "Alert: Preventing Needlestick Injuries in Health Care Setting," on Nov. 23, 1999, urging hospitals to adopt safety devices. The recommendations also call for employers to adopt strategic measures to protect health care workers from work-related injuries caused by needles in syringes, intravenous delivery systems and other medical devices. NIOSH estimates that yearly 1,000 health care workers become infected with Hepatitis or HIV.

For Academy members and other health care workers, education and awareness about safety devices are critical factors, says Dr. Florence.

"But the problem comes with orthopaedic surgeons injuring their hands doing surgical procedures. And physicians can’t use those safe needle devices to do an injection or aspiration in the OR–we have to use regular bare needles. With the use of education, implementation of newer safety measures and also utilization of instruments to handle sharp bone fragments, rather than with the gloved hand, we should be able to reduce the incidents of needlesticks and sharps injuries considerably."

"I think we’d best serve the interest of our patients by trying to get these devices," says Peter J. Mandell, MD, who will become chair of the occupational health committee in March and was a proponent of the Cal/OSHA safe needle bill. "The safe needle devices are more expensive and it might cost another $500 or $1,000 for physicians or hospitals to purchase them," he says. "But I think we would not be on the right side of things if we started arguing these things should not be done."

OSHA’s directive is available online http://www.osha.gov under the "Directives" link.

Physicians can access info on the Alert by visiting http://www.cdc.gov/niosh

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