Эпидемия ВИЧ/СПИДа научила медицину: для нулевого травматизма нужно менять системы, а не только инструменты

What HIV/AIDS Taught Health Care About Needlesticks and Occupational Exposure A needlestick injury happens in seconds. Its cause may have started hours earlier. Amy Piser argues that getting closer to “sharps injury zero” requires health care organizations to stop focusing solely on the moment of injury and start examining the systems surrounding it. Sharps safety has changed dramatically over the past several decades, but needlestick and other sharps injuries remain a preventable occupational hazard for health care workers. The HIV/AIDS epidemic fundamentally altered how clinicians understood the risks associated with needles and exposure to bloodborne pathogens, accelerating practices such as eliminating needle recapping, introducing safety-engineered devices, improving sharps disposal, and strengthening training and other workplace protections. Yet even with decades of experience, injuries continue to occur. In this Infection Control Today® (ICT®) Q&A, Amy Piser, director of process improvement, clinical education at Daniels Health, reflects on lessons from the HIV/AIDS epidemic in Australia and examines why health care organizations still struggle to achieve “sharps injury zero.” Piser argues that prevention requires looking beyond the actions of the individual health care worker to upstream factors such as workload, room design, container placement, device selection, education, and organizational systems. She also discusses the importance of frontline involvement in safety-device selection and explains why meaningful root-cause investigations should be used to identify opportunities for prevention rather than assign blame. ICT: During the height of the HIV/AIDS epidemic in Australia, how did the risk of occupational HIV exposure change the way health care workers thought about needles and other sharps, and which practices introduced during that period still influence sharps safety today? Amy Piser: Prior to the HIV/AIDS epidemic, needles and other sharps were recapped by hand and sometimes reused as standard practice. The risk of exposure to HIV/AIDS, as well as hepatitis B and C, seriously changed the way health care workers thought about needles and sharps. For the first time, clinicians understood the risk associated with needlestick injuries and began implementing engineering and administrative controls, as well as personal protective equipment (PPE), to improve safety outcomes for practitioners and patients alike. In the US, much of this was codified in the Bloodborne Pathogens Standard produced by the Occupational Safety and Health Administration in the early 1990s. Solutions such as sharps-specific disposal containers and safety-engineered devices began to be instituted across health systems, and many of those same solutions remain in place today. ICT: Decades after the risks of bloodborne pathogen exposure became well understood, health care workers are still experiencing preventable sharps injuries. Why do these injuries continue to happen, and where are health care systems still falling short? AP: There are several reasons why sharps injuries may still occur, despite putting the right systems in place to make them as avoidable as possible. We saw during the pandemic that high rates of exhaustion and overwork led to an increase in needlestick injuries—tired, distracted, or stressed practitioners are more likely to make mistakes that may lead to a needlestick. Another factor is patient room design: sharps disposal containers should ideally be located as close as possible to the point of waste generation. If a clinician must move across the room to dispose of a needle, that increases injury risks. Lastly, it is difficult to control for proper training across all practitioners in all health care settings. Without proper knowledge, such as never recapping a needle, the risk of accidental injury increases. Even with proper training, we sometimes see practitioners take shortcuts that put themselves or others at risk. For example, we’ve seen clinicians place needles on top of a container when the tray is full, putting an EVS worker at risk. It’s understandable when people are moving fast, but the risks far outweigh the rewards. However, with the right systems in place and the right training for practitioners, injuries should be close to zero. ICT: When a sharps injury occurs, we often focus on what the individual was doing at that moment. How frequently is the real cause upstream, such as device selection, staffing, workload, workflow design, disposal-container placement, inadequate training, or organizational culture? AP: These upstream causes are definitely a primary culprit. While there will always be the inevitable accident, at Daniels Health, we believe that controlling these upstream challenges as much as possible—putting the right engineering and administrative controls into place—goes a long way towards achieving “sharps injury zero.” It’s also important to consider practitioner workload, not just focus on the incident at the time. When evaluating a person’s workload as a whole, we may see that an overloaded schedule leads to a mistake more so than the wrong safety controls in place. ICT: Have improvements in HIV treatment and postexposure management unintentionally changed perceptions of occupational risk? Is there a danger that health care workers or organizations have become less vigilant about sharps safety because HIV is now a much more manageable disease? AP: I don’t think that this is the case. No one wants to deal with the burden of a needlestick injury, the documentation, the testing, the lack of certainty. And while it is true that treatment for HIV is much better than it was even a few years ago, it is still an incurable disease. If anything, we now have multiple generations of health care professionals who have grown up in a world of sharps safety awareness, so vigilance is much more ingrained in their everyday practices. ICT: Safety-engineered devices have been available for years, yet injuries still occur. What makes a safety device genuinely effective, and how important is involving the frontline workers who use these products in their selection and evaluation? AP: The best safety-engineered devices are those that take the guesswork out of safety. For example, our Sharpsmart sharps containers have several built-in safety features that make it incredibly difficult for an accidental sharps injury to occur. From impenetrable plastic to a gravity-activated disposal tray to automatic “full” locking mechanisms, the product is designed to make it nearly impossible to hurt yourself when used properly. We take our practitioners’ input very seriously in the design and iteration of our products. They are the ones who use it every day, and we need to understand and implement their feedback. Also, if they are part of the process, they are more likely to comply with the proper use of the safety device, so it’s a win-win. ICT: What can organizations learn from the circumstances surrounding a sharps injury beyond simply documenting that it occurred? What should a meaningful root-cause investigation examine, and how can those findings be translated into prevention rather than blame? AP: I’ve seen facilities where they just record the necessary minimum for root cause. But the best course of action is to dive deeply into what happened and examine the extenuating circumstances to properly understand the causal factors. Really looking deeply into the root cause and breaking it down into granular detail is a strong practice. This, combined with an active sharps injury committee—a group that reports it out to leadership—helps drive change. You can’t change what you don’t measure. Making metrics available drives awareness and supports positive change. ICT: Looking back at Australia's response to HIV/AIDS and forward to today's health care environment, what is the most important lesson we have learned about protecting health care workers from occupational bloodborne pathogen exposure, and what lesson do you think health care systems have forgotten? AP: I think the most important takeaway from the HIV/AIDS crisis and the past 40-plus years of sharps safety in general is that there is not one single solution. Hospitals and health systems need to combine engineering controls, such as safety-engineered devices, and administrative controls, such as proper training and education, to create a system that keeps people safe. I don’t think health care systems have forgotten that lesson, but I do think it is important to continually remind the people on the front lines every day of the importance of proper sharps safety. With proper systems and training in place, we routinely see a measurable reduction in sharps injuries. Maintaining high safety standards requires vigilance, and that is what we are committed to with our education and training at Daniels Health.