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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