Download What is health care worker safety?

What is health care worker
safety?
Prepared for the SafeHandS network by
Albion Street Centre, Sydney, Australia
www.uow.edu.au/health/safehands/index.htm
Sections
•
•
•
•
•
•
What is SafeHandS?
What is health care worker safety?
Why is it important?
How can it be improved?
How can it be measured?
What will it cost?
What is SafeHandS?
What is SafeHandS?
• A ‘virtual’ network designed to link and
support health care workers (HCWs) in the
Asia-Pacific region who are caring for people
with HIV and other communicable diseases
• A forum where HCW can share issues and
ideas and encourage and learn from each other
to find practical solutions to improve health
care worker safety in low and middle income
countries
What is SafeHandS?
Free membership of SafeHandS includes:
• Receiving a newsletter every 3 months
• A moderated group email discussion e-list for
posting questions, comments and issues
• Access to a clearinghouse of new resources &
publications (links are posted on the website)
• Access to resources developed by SafeHandS
• Access to a database of expertise
What is health care worker
safety?
What is health care worker safety?
Protection from transmission of
– blood borne pathogens (eg HIV, HBV)
– respiratory zoonoses
– tuberculosis, SARS, seasonal and pandemic
influenza
– and other infections
to staff in health workplaces
Principles of HCW safety
• Reduce HCW susceptibility to infection
• Reduce potential for occupational exposures
• Manage occupational exposures
• Maintain health of infected HCW
Guidance Note on Health Care Worker Safety
from HIV and other Blood Borne Viruses
http://siteresources.worldbank.org/INTEAPREGTOPHIVAIDS/
Resources/Guidance_Note.pdf
Elements of HCW safety
• Health promotion
• Safe use and administration of injections
• Safe use and disposal of medical sharps
• Infection prevention and control
• Management of exposures
How is HCW safety different from
infection control?
• Primary goal of infection control - to prevent
infection spreading in health care
environments
• Infection control includes prevention of
infection to HCW, but the emphasis is on
protecting patients
• HCW safety is a special topic within infection
control
Why are HCWs not safe?
Probable reasons HCWs put themselves at risk of
acquiring blood borne viruses
•No effective infection control (IC) policies/ procedures
•Misunderstanding of, or non-compliance with, IC
procedures
•Perceived lack of resources for IC procedures
•Lack of adequate resources and training in quality
improvement practices in health care
•Denial or ignorance of risks
Why is health care worker
safety important?
HCWs are a valuable resource
Health care workers are essential:
• To care for the sick
• For health promotion programs to prevent
illness
• For the success of treatment programs such as
directly observed therapy for tuberculosis or
antiretroviral therapy for HIV
Everything possible should be done to
keep experienced HCWs because:
It is expensive
• To educate HCWs
• To recruit HCWs
• To provide on-the-job training
It is important
• To maintain “corporate knowledge”
• To have trainers for junior staff
If HCWs do not feel safe
They may:
• Be anxious – for self and/or family
• Feel insecure in their work
• Change jobs
• Leave health work
• Treat some patients differently
If HCWs do not feel safe
Patients may experience:
• Discrimination
• Denial of access to some procedures
• Sub-standard treatment
• Denial of basic care
• Quarantine
• Breach of confidentiality
Benefits of HCW safety programs
• Reduced fear
• Staff feel supported
Leads to:
• Reduced absenteeism and attrition
• Cost savings
• Improved patient care
• Better prevention programs
• Better treatment programs
Benefits of HCW safety programs
• Improving HCW safety plays an important role
in the quality of treatment and care for patients
with HIV and other infectious diseases like
tuberculosis, SARS, avian influenza and
emerging infectious diseases
How can health care worker
safety be improved?
Principles of HCW safety
1. Reduce HCW susceptibility to infection
2. Reduce potential for occupational exposures
3. Manage occupational exposures
4. Maintain health of infected HCW
Guidance Note on Health Care Worker Safety
from HIV and other Blood Borne Viruses
1. Reduce susceptibility to infection
• Vaccination programs
– Provide vaccination against hepatitis B (HBV) and
other vaccine preventable diseases
– Or inform workers about the benefits of
vaccinations and how to access them
Guidance Note on Health Care Worker Safety
from HIV and other Blood Borne Viruses
Reduce susceptibility to infection
• Health education programs
– Wellness education (protection from blood borne
viruses and other diseases in everyday life)
– Staff health clinics
– Staff counselling/support services
Guidance Note on Health Care Worker Safety
from HIV and other Blood Borne Viruses
Health promotion messages –
wellness education
• Safe sexual practices
• Safe needle use
• Safe skin piercing (tattooing, ear piercing,
electrolysis, botox injections)
• Home hygiene (handwashing, not sharing
personal hygiene or grooming items such as
razors or toothbrushes)
2. Reduce potential for occupational
exposures
•
•
•
•
•
•
•
Engineering controls
Adopt and use standard (universal) precautions
Supervision of less experienced staff
Staff education
Manage and dispose of waste safely
Address occupational health and safety issues
Safe sharps handling and injection safety
Guidance Note on Health Care Worker Safety
from HIV and other Blood Borne Viruses
Infection control
Prevention of transmission of infection to
anyone to whom the organisation owes a duty
of care, including:
patients, HCWs and other employees,
contractors, visitors, students
Includes:
Safe work practices
Standard (universal) precautions
Safe sharps handling
Standard (universal) precautions
Standard precautions are “designed to reduce
the risk of transmission of micro-organisms
from both recognised and unrecognised
sources of infection in health organisations”
NSW Health Department Policy Directive 2007_036 Infection Control Policy: 12
Standard (universal) precautions
Apply to all patients regardless of diagnosis
• Minimum acceptable level of practice
• Apply to:
• blood
• all body secretions except sweat
• non-intact skin
• mucous membranes
NSW Health Department Policy Directive 2007_036 Infection Control Policy: 12
Standard (universal) precautions
Body fluids of all people are considered to be
potential sources of infection
Used because:
•
•
•
•
person may not have been tested
person may be in the window period
cannot tell who is infected
cannot tell who has been at risk
MAKING ASSUMPTIONS ABOUT
ANYONE CAN BE DANGEROUS!
Injection safety
Many of the billions of injections given each
year are unnecessary
– Injections are often believed to be more effective
than other treatments
– Correlation between the frequency of injections
and the prevalence of HBV, HCV (hepatitis C
virus) and HIV
– Unnecessary injections also increase risk for
HCWs (increased handling of sharps)
Injection safety
Safe Injection Global Network
http://www.who.int/injection_safety
Safe Injection Global Network
http://www.who.int/injection_safety
Injection safety
Three-element approach
1- Behaviour change
2- Safe equipment and supplies
3- Sharps waste management
Safe Injection Global Network
http://www.who.int/injection_safety
3. Manage occupational exposures
• Encourage reporting
• Simple, accessible protocols
• First aid
• Risk assessment
• Post exposure prophylaxis
• Testing
• Support
• Follow up
Guidance Note on Health Care Worker Safety
from HIV and other Blood Borne Viruses
Manage occupational exposures
Why do it?
• Helps to prevent infection
• Makes HCW feel safer
• Makes HCW feel supported
• Improves patient care
• Accepted best practice (World Health
Organization, International Council of Nurses)
Occupational exposures in health
Literature review of retrospective surveys
• In all countries and settings - many needlestick
injuries annually (up to 90% of HCW)
• Most studies show less than 60% reported
• Sudden patient movement & two handed
recapping of needles - most commonly
reported cause of exposure
• Suturing – most common procedure
In SafeHandS 1(2) Oct 05
Why are staff reluctant to report
exposures?
Possible answers
• Unaware of risk
• Afraid of breach of confidentiality
• Afraid of blame, stigma
• There is no treatment/prophylaxis
• Attitudes of others
• Complicated reporting and management
process
• Discouraged by management
Risk assessment – occupational exposures
Most statistics are from countries with:
• Comparatively low prevalence rates
• Well developed reporting and surveillance systems
• Post exposure prophylaxis (PEP)
Risk is probably greater in countries with
• Higher prevalence rates
• Large numbers of patients with untreated advanced
disease
• Little provision for giving PEP
Factors in risk assessment for
occupational exposure to HIV
Source
HIV antigen positive, high viral load,
symptomatic, diagnosis of AIDS, terminally ill
Exposure Percutaneous, rarely mucocutaneous
Deep injury
Needle
Hollow (not solid); large bore
Used to draw blood
Fluid
Blood or concentrated virus
Volume; Contact time
Gloves
Decrease fluid contact if worn
Protect against exposure by about 60%
Risk of infection following needlestick injury from infected source
Antibody/antigen status
Risk/needlestick
HBeAG +ve
30-40%
HC Ab +ve (PCR +ve)
10%
HbsAg +ve
2-6%
HC Ab +ve (PCR –ve)
1%
HIV Ab +ve
0.3%
Clinical management of HIV-PEP
Eligibility
•Exposure within 72 hours
•Exposed individual not
known to be HIV-infected
•Significant exposure
•Source of exposure HIVinfected or unknown
Informed consent for PEP
Information about risks
and benefits. Need not be
written
WHO/ILO 2007
Clinical management of HIV-PEP
Medications
Two NRTI*s (usually first
line ART drugs)
Time to initiation
Initial dose should be given
as soon as possible, but no
later than 72 hours, after
exposure
Duration of therapy
28 days
* non-nucleoside reverse transcriptase inhibitors
WHO/ILO 2007
Post exposure prophylaxis
Also consider prophylaxis for
• HBV
• Tetanus
Potential model support service :
Needlestick Injury Hotline
•
•
•
•
•
•
Toll free number – state-wide
Connect to paging service
Call back within 15 minutes
Adjunct to local services
Not primary management
Telephone support, information, advice for
exposed person, managers, clinicians
Needlestick Injury Hotline
• The NSW Needlestick Injury Hotline is a very
effective service that gives accurate
information to allay the fears and concerns of
workers following an occupational exposure
and also provides direction for the
management of the exposure
• It is also a relatively easy and cheap model to
establish
4. Maintain health of infected HCWs
•
•
•
•
•
Protocols which support infected HCWs
Assurance of confidentiality
Appropriate work practices
Infection control standards
Compensation for occupationally acquired
disease
Guidance Note on Health Care Worker Safety
from HIV and other Blood Borne Viruses
Maintain health of infected HCWs
•
•
•
•
Supporting HCWs infected with blood
borne viruses is likely to:
Encourage disclosure of status
Encourage reporting of exposures
Retain experienced HCW
Set examples for treatment of infected patients
Resources
• International Labour Organization (2001)
An ILO Code of Practice on HIV/AIDS and
the World of Work
Geneva
http://www.ilo.org/public/english/protection/sa
fework/cops/english/download/e000008.pdf
Key principles
• International Labour Organization –
identified ten key principles which apply to all
aspects of work and all workplaces, including
the health sector
ILO code of practice on HIV/AIDS and the world of work (2001)
Key principles 1
1. The workplace can play a vital role in limiting the
transmission and effects of HIV
2. There should be no discrimination against workers
on the basis of HIV status
3. Gender equality is vital
4. The workplace should minimise occupational risk
5. A successful HIV/AIDS program needs cooperation
and trust between employers, workers and
governments
ILO code of practice on HIV/AIDS and the world of work (2001)
Key principles 2
6. Testing for HIV should be voluntary and
confidential, and never used to screen job applicants
or employees
7. A worker’s HIV status should be confidential
8. Workers with HIV should be able to work for as
long as they are medically fit
9. Information, education and support should be
provided for behaviour change
10. Workers are entitled to affordable health
services
ILO code of practice on HIV/AIDS and the world of work (2001)
Question
What things prevent the
implementation of policies and
practices to improve health care
worker safety?
Possible answers
• Lack of resources
• Assumption that safety is expensive
• Not seen as cost effective
• Not a high priority
• Lack of government or management support
Strategies which do NOT improve
safety
x Testing all patients
• Test results may be negative but patient may
be infectious
• Leads to lower standard of infection control
x Using different procedures or equipment for
patients with HIV or hepatitis
• All procedures should be able to protect
against unknown infection
What is needed for HCW safety?
•
•
•
•
•
•
National or regional strategy
Local policy and implementation guidelines
Institutional commitment and support
Realistic protocols
Allocation (or re-allocation) of resources
Education
– transmission of infection
– situational analysis (prioritising resource use)
• Information (data collection) on exposures
• Evaluation and review
How can health care worker
safety be measured?
Measuring HCW safety –
the literature
Articles on HCW safety are usually studies of:
• Retrospective surveys of:
– Numbers and type of exposures, level of reporting,
knowledge of risks and protocols
• Costs of exposures
• Epidemiology of exposure risk and infection
• Psychological and physiological
consequences of exposures
HCW safety surveillance
Baseline information on HCW safety is essential:
• to show what is happening now
• to estimate the costs of current and planned
measures
• to demonstrate a need for interventions
• to evaluate any interventions implemented
HCW safety surveillance tool
• SafeHandS has developed a draft tool to
measure and calculate costs for HCW safety
• It will give baseline and follow up data to
measure safety and evaluate interventions
• The draft is available on the SafeHandS
website: www.uow.edu.au/health/safehands/index.html
• Members are invited to use the tool and submit
results, comments, or suggestions
What will health care worker
safety cost?
What will HCW safety cost?
• Assumption that increased resources needed to
increase safety
• May not be able to achieve same level of
safety as resource rich country
• But can probably increase safety by reallocation of resources and low- or no-cost
interventions
What will HCW safety cost?
• Prioritise use of control measures
– If resources limited, use to protect against
most risky procedures NOT against patients
perceived to be at risk
• Use the aspects of international best practice
that can be modified for local conditions
– Can do something if not everything
Example – Safe sharps handling
What IS important about sharps containers?
• Puncture resistant
• Leakproof
• Labelled
• Recognised by all staff
This can be achieved with recycled containers
What will HCW safety cost?
x
x
x
x
Reduce costs by stopping expensive and
unnecessary practices, such as:
Putting dirty equipment or sharps directly into
disinfectant
Wearing gloves to make beds
Inappropriate or extended wearing of masks
Burning or discarding linen and equipment
used by patients with HIV or hepatitis
What will HCW safety cost?
Low- or no-cost safety interventions
• Standard Precautions
• Modify techniques to reduce sharps handling
• Make the person who uses the sharp
responsible for its disposal
• No open-toed footwear for clinical staff
• Supervise inexperienced staff
• Encourage reporting, first aid and risk
assessment after exposures
Resources
• SafeHandS
– Network for HCW safety
– Free membership and support
– [email protected]
• SafeHandS Website
– Resources and links for HCW safety
– Newsletter archives
– www.uow.edu.au/health/safehands/index.html
Resources
Gold J, Tomkins M, Melling P, Bates N (2004)
Guidance Note on Health Care Worker Safety
from HIV and Other Blood Borne Infections
Health, Population and Nutrition Discussion Paper.
The World Bank. Washington, D.C., USA
http://siteresources.worldbank.org/INTEAPREGTOPHIV
AIDS/Resources/Guidance_Note.pdf
Resources
World Health Organization/International Labour
Organization (2007)
Post-exposure Prophylaxis to Prevent HIV
Infection: Joint WHO/ILO Guidelines for the
Use of Occupational and Non-occupational
Post-exposure Prophylaxis (PEP) to Prevent
Human Immunodeficiency Virus (HIV)
Infection Geneva, Switzerland. In press
Resources
• WHO Injection Safety Toolkit includes:
– Managing an injection safety policy
– Guiding principles for injection device security
– Best infection control practices for skin piercing
and injections
– Guidelines for assessing, planning, implementing
& evaluating injection safety
http://www.who.int/injection_safety/toolbox/toolbox/en/index.html