black belt final projectporourke copy 2

Reducing Contaminated Needle Sticks at a Large Healthcare System Using Six Steps to 6 V

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Reducing Contaminated Needle Sticks at a Large Healthcare System

Using Six Steps to Six Sigma

Final Project

Patricia O’Rourke

Aveta Business Solutions

December 2009


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Step 1 Project selection and charter Identify opportunity for improvement (problem description)

Contaminated needle sticks are occurring among our healthcare workers. These injuries are frightening and can be devastating. The patient whose blood was pricked into the nurse or medical assistant, lab tech, or other healthcare worker can be contaminated with Hepatitis B or C or HIV/AIDS. Once the blood-borne pathogen exposure has occurred the employee has to undergo tests to rule out these diseases. During this time there is fear and worry. The employee may have to take antiviral medications until their tests come back and until the patient’s blood is tested. These medications cause severe nausea, vomiting, and weakness. The employee is unable to work during this time. These injuries must be stopped. They can and will be prevented.

In November 2000, both houses of Congress approved the Needlestick Safety and Prevention Act. The act was signed into law and gave OSHA a mandate to revise the Bloodborne Pathogens standard to include requirements for safe medical devices to eliminate or minimize occupational exposure to bloodborne pathogens through needlestick and other sharps injuries. On April 16, 2003, just prior to the deadline for meeting the OSHA requirements, our suppliers and manufacturers of safe needle devices sent letters to their customers stating they would no longer carry conventional needles and syringes to be in accordance with the OSHA Needlestick Safety and Prevention Act.

Identify sponsor

Quality + Teamwork = POWERFUL MEDICINE In 2000 the Broward Health Environment of Care Key Group challenged the organization to reduce contaminated needle sticks. The organization was to get historical data on these injuries, analyze the causes, and create processes and procedures to prevent them. The Environment of Care (EoC) Key Group is the corporate-level safety committee headed by the corporate Vice President and Chief Operating Officer and by the Director of Risk Management. The members of the committee are the hospital Safety Officers, Facilities Services Managers, Infection Control, Workers Compensation, Security, Corporate Compliance, the COO of Broward General Medical Center, and the Director of Quality and Performance Improvement Estimate savings Workers Compensation records, along with Employee Health Nursing, are able to supply the exact cost of each case over the past several years. A preliminary estimate of the cost savings has to include lost time, medical care, lab work, medications, and transportation. Perhaps $50,000 a year will be saved or avoided by eliminating these injuries.


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Draft project charter and scope The preliminary charter drafted by the EoC Key Group includes the mandate to review all records relating to the contaminated needle sticks, create a list of the activity being performed, the device used, the worker job title, and how, when, and why the stick occurred. From this data the team is to create prevention measures involving the key stakeholders in this endeavor and include the manufacturers and suppliers of the devices. In addition a Safe Needle Device Committee was formulated to study new safety devices on the market. Sponsor project review The EoC Key Group will be looking for demonstration of these work breakdown structures (WBS), to better understand the leading causes of the sticks, as well as the creation of Pareto charts that delineate the percent of the leading causes so that each cause can be addressed.

Step 2 Define Team selection A team was created consisting of Safety Officers, Nursing, Workers Compensation, Infection Control, and Employee Health. The team will call upon ad hoc members from the Lab, Interventional Radiology, Respiratory Therapy, Finance, and Purchasing. These members will be familiar with employee accident reporting, workers compensation tracking, OSHA recordkeeping, and the multiple processes and procedures that require the use of needles. Team training Team training is to consist of how and where to gather essential information, sharing knowledge on conducting root cause analysis, how to identify our customers (stakeholders), creating Pareto and Gantt charts, running metrics on cases per 10,000 adjusted patient days, and an individual is assigned to conduct a literature search and to start benchmarking.

A Gantt chart is to be created with a list of tasks, sub-tasks and projected timelines for completion. There are to be expected deliverables reported upon regularly showing in-depth knowledge of causes, contributing factors, and methods of prevention and education.


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21

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Six Sigma refers to this tiny area under

the bell curve where the

probability of producing a defect

is almost nil!

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Review existing process The processes or procedures that require the use of needles are identified and analyzed for opportunities for a stick. These steps in the process are listed and actions are identified that can cause and prevent a stick. Define projects and plan The team members are given various tasks to perform that enable them to define the problems, opportunities for improvement and outcomes or goals of the performance improvement project. The Gantt timeline can then be established and be continually updated as more data comes in. Present objectives and plan to management, our sponsor The team is ready to present progress and findings to the Environment of Care Key Group on a regular basis. The EoC Key Group represents management and at the same time they are the team’s sponsor. With this charter in place the team is empowered to conduct research and recommend solutions. Define and map “as is” process The processes are multifaceted and currently demonstrate all of the occasions a healthcare worker can be stuck by a sharp or needle. Each step in the process or procedure for drawing blood, administering an injection, starting an IV, removing and IV, obtaining arterial blood gases, obtaining cultures and specimens, are listed along with noting the “danger” areas. One of the danger areas is sticks that also happen during disposal. Review, redefine problem Beginning in 2005 all 4 hospital Safety Officers added this metric to the corporate-level dashboard. They measured and reported upon the number of contaminated needle sticks to the Key Group with a normalizer of 10,000 adjusted patient days (APD), and went back to data from 2000, setting a threshold rate of 3.00 (contaminated needle sticks per 10,000 APD).

The team will be trained in the concept of measuring defects per million opportunities (DPMO), the meaning of Six Sigma, and the six steps to Six Sigma (Project plus DMAIC).


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Broward Health Hospitals Total Contaminated Needle Sticks per 10,000 APD

with Trendline Against Threshold of 3.00

0.000.501.001.502.002.503.003.504.00

2000 2001 2002 2003 2004 2005 2006 20070.000.501.001.502.002.503.003.504.0035% Decrease

Pareto of Causes of Needle Sticks

in FY 2004 BH-wide

05

10152025303540

Other, S

urgica

l, IM

Dispos

al

Phlebo

tomy

Featur

e not

Activa

ted

Patient

Related

Incorre

ct Dev

ice

Safe D

evice

not A

vaila

ble

Num

ber

0%5%10%15%20%25%30%35%40%45%50%

Perc

ent

Number Percent Most sticks were due to unsafe passing of sutures or instruments during surgery and the use of non-safety IM needles. The next most frequent cause was disposal related, including 4 sticks from needles being placed in the trash impacting environmental services staff. The butterfly device injuries reduced, but incorrect devices were still being used or the safety devices were not activated. Awareness and training increased and manufacturer Reps from B-D and Kendall continued to provide support and on-site education with the help of the Safe Needle Device Committee.

Total Number of Contaminated Needle Sticks by Broward Health Hospital

0

10

20

30

40

50

60

70

80

2000 2001 2002 2003 2004 2005 2006 2007

BGMC NBMC IPMC CSMC Among the Broward Health hospitals alone the team saw a reduction of 23% (from 119 in FY 2000 to 92 in FY 2007) in number only (not measuring it against adjusted patient days, number of employees, or DPMO).

The threshold not to exceed was set at 3.00 because this was the highest historical level. Since 2001 the hospitals have been below the threshold. By year-end 2007 the trend showed a 35% decrease over 2000.

After compiling system-wide data the team noticed a slight increase (17%) in the number of sticks in fiscal year ’04, so a drill down was done to determine the root causes and a Pareto chart of the causes was created.

The team looked at the number of sticks in the 4 hospitals only, breaking that data away from the satellite sites of Community Health Services.


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Community Health Services (inc. CDTC, GCHH; exc. WR, Practices) Contaminated Needle Sticks per 1000 Medical

Encounters Against Threshold of 0.04

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

FY 2003 FY 2004 FY 2005 FY 2006 FY 20070.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

95% Reduction Since 2003

Complete project charter The project charter is complete once the problem is defined and broken into various processes and procedures. The EoC Key Group asked the team to analyze the causes, costs, and prevention tactics to be delivered. The team, with the knowledge obtained, is now able to describe improved methods, techniques, and devices that will greatly reduce contaminated needle sticks. Step 3 Measure Identify those metrics deemed critical to quality (CTQ) The team was able to define contaminated needle sticks as defects in the system in the provision of care. They measured these defects per million opportunities. The opportunities for error are one stick per employee per workday. The team has also measured the sticks against 10,000 Adjusted Patient Days (APD). This metric is used for other quality measures at Broward Health, so proves to be readily identifiable by management.

The team and the Safe Needle Device Committee studied safety device use, provided new safety devices and watched the trends regarding their availability and use. In 2003 nine percent (9%) of contaminated needle sticks were due to lack of an acceptable safety device and 10% were due to using the safety device incorrectly.

In Community Health Services, including Childrens’ Diagnostic & Treatment Center and Gold Coast Home Health and Hospice, contaminated needle sticks reduced 95% since FY 2003, with a threshold of 0.04 per 1000 medical encounters.

Safety Device-Related Needle Stick Injuries as Cause Trend by Fiscal Year

05

10152025303540

2003 2004 2005 2006 2007

Incorrect Device Used Safety Feature not Activated Safety Device not Available


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FY 2003 Cause of Needle Sticks by Percent

Phlebotomy, 21%

Patient Related, 12%

Disposal Related, 9%

Safety Feature not Activated,

27%

Safety Device not Available,

9%

Other: IV, Sutures, IM,

13%

Incorrect Device Used,

10%

FY 2007 Cause of Needle Sticks by Percent

Other: IV, Sutures, IM,

35%

Safety Feature not Activated,

11%

Safety Device Not Available,

0%

Incorrect Device Used,

0%

Disposal Related, 16%

Patient Related, 24%

Phlebotomy, 15%

The team and its counterparts continued to work with the vendors and conducted training such that by fiscal year-end 2007 there were no cases of a device not being available and no case of using a device incorrectly.

Numerous safe needle devices and needle-less devices were obtained and evaluated over several years as they became available. The team and stakeholders tested and purchased devices consistently after demonstrations by vendors and trials by multiple nursing and lab staffs throughout Broward Health. After implementation continual training took place by the vendors/suppliers of Becton Dickinson.

BD Eclipse™ injection needle offers single-handed activation No hard surface required for activation; Bevel--oriented needle allows for low-angle injections. PrecisionGlide™ needles minimize injection pain and patient discomfort

BD Integra™ syringe with Retracting PrecisionGlide™ needle The BD Integra™ syringe provides clinicians with the latest advances in retracting technology. The BD Integra syringe offers the following advantages:

BD SafetyGlide™ insulin syringe with permanently attached needle; the only single-handed device that is available in 1/2 ml and 3/10 ml sizes.


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Collect data on subtasks and cycle time The data on subtasks and cycle time related to contaminated needle sticks were obtained from in-depth review of the accident reports and review with the Employee Health Nurses as well as Workers Compensation. This was measured and demonstrated in Pareto charts. Validate measurement systems

The measurement systems were multifaceted and included the tasks involved, the device used, and the narrative given by the injured staff member as to activity and cause. These were measured by number, cost, against manhours worked, adjusted patient days, and defects per million opportunities.

Total Number Contaminated Needle Sticks Broward Health-wide

And Trendline

020

406080

100120

140160

2000 2001 2002 2003 2004 2005 2006 2007

29% Reduction Since 2000

Broward Health Hospitals Total Contaminated Needle

Sticks per 10,000 Productive Manhours and Trendline

0.0000.0250.0500.0750.1000.1250.1500.1750.200

2000 2001 2002 2003 2004 2005 2006 2007

41% Decrease

Contaminated Needle Sticks Annual Trend

Against Threshold

0.000.501.001.502.002.503.003.50

BGMC CSMC IPMC NBMC0.000.501.001.502.002.503.003.50

2005 2006 Threshold

Across the Broward Health system the number of contaminated needle sticks was reduced by 29% from 131 in FY 2000 down to 93 in FY 2007.

The number of sticks per 10,000 productive man-hours system-wide showed a 41% decrease over the 7 years since 2000 in this metric

During both FY ’05 and FY ’06 the hospitals came in well under the threshold of 3.00; 32% below threshold in FY ’05 and 47% below in FY ’06.


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Each hospital had a significant reduction in rate per 10,000 APD. BGMC reduced contaminated needle sticks by 12%, CSMC 38%, IPMC 36%, and NBMC by 6%.

Contaminated Needle Sticks District-set 3 per 10,000 APD (# of cases/Total APD) X 10,000

Rate 2005 2006 Threshold Percent Reduction BGMC 2.24 1.98 3.0 12% CSMC 2.40 1.50 3.0 38% IPMC 1.45 0.93 3.0 36% NBMC 2.08 1.96 3.0 6%

Average 2.04 1.59 3.0 22% Reduction District-Wide A study in the July ’07 issue of Infection Control and Hospital Epidemiology found that “costs for occupational bloodborne exposures ranged from $71.00 to $4,838.00 per incident, depending on the circumstances. Calculations included time spent reporting, managing and following up on the exposures, salaries, laboratory testing, and post-exposure prophylaxis. The mean cost of exposures was $2,456.00 from HIV infected sources; $376.00 from unknown or HIV-negative infected sources;; $650.00 from Hepatitis C infected sources.” The team obtained exact data on the cost of contaminated needle sticks for fiscal year 2006 and the first half of fiscal ’07 system-wide. In FY ’06 contaminated needle sticks cost $47,246.00 for a total of 97 sticks. In the first half of FY ’07 the cost was $39,372.00 for 47 contaminated needle sticks. That is $86,618.00 in 6 quarters for 144 contaminated needle sticks.

NBHD Cost of Contaminated Needle Sticks FY '06 and FY '07 YTD

$50,597

$18,741 $17,280

$86,618

$0$10,000$20,000$30,000$40,000$50,000$60,000$70,000$80,000$90,000

$100,000$110,000

W/C Costs Lab Costs Employee HealthCosts

Total Cost

Avg. Cost $602.00

NBHD Contaminated Needle Sticks Cost Avoidance

Year over Year Compared to Baseline

$0$10,000$20,000$30,000$40,000$50,000$60,000$70,000$80,000$90,000

$100,000

2000 2001 2002 2003 2004 2005 2006 2007$0$10,000$20,000$30,000$40,000$50,000$60,000$70,000$80,000$90,000

Cumulative Cost Avoidance Year Over Year Compared to Baseline $135,942

When the team looked at the cost of these defects in the system they could show that their efforts have avoided $135,942.00 in cumulative costs to Broward Health year over year from the baseline of $78,798.00 in 2000.

The average cost of a single contaminated needle stick was then determined to be $602.00.


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NBHD Cost of Contaminated Needle Sticks District-wide and Trendline

$0

$20,000

$40,000

$60,000

$80,000

$100,000

2000 2001 2002 2003 2004 2005 2006 2007

In other words, if all stayed the same and no efforts were made to implement safe needle devices and conduct training in avoiding contaminated needle sticks Broward Health would have paid 136K for the cost of contaminated needle sticks over the subsequent seven years. When the employee has an adverse reaction to the treatment for HIV, for instance, and loses time from work due to illness a single contaminated stick can cost well over $1,000.00 in direct costs.

37

The Net Cost of InjuriesThe Net Cost of Injuries

Direct Costs• Medical Costs• Indemnity Payments

Indirect Costs• Lost Time By: • Schedule Delays

Injured • Training New EmployeesSupervisor • Overhead CostsFellow Workers • Spoiled Product

• Legal Fees • Increase in Insurance • Unhappy Customers • Cleanup Time

On average, indirect costs exceed direct costs by a 4:1

ratio

“Iceberg Model”

NBHD Total Cost of Contaminated Needle Sticks Including Hidden Costs

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

2000 2001 2002 2003 2004 2005 2006 2007

Direct Cost Hidden Costs 10:1 Total Cost

The team considered that all accidents have hidden costs. According to the National Safety Council these costs can be anywhere from 4 to 10 times the direct, known costs. This is the iceberg model. The reason is that there are costs related to the time it takes for completion of paper work, insurance premiums, attorney’s fees, replacement workers, training, and more.

Therefore, stated costs ranging from $51,000.00 to $87,000.00 actually cost the system $569,000.00 to $867,000.00 per year when hidden costs are included.

Analyzing the data historically, back to FY 2000, the team showed that the direct cost of contaminated needle sticks has gone down, trending in the right direction.


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Step 4 Analyze Prepare baseline graphs on subtasks and cycle time The subtasks involved in contaminated needle sticks were analyzed for the 12 month period of August of 2008 to August of 2009. The team looked at the sub-tasks involved at the immediate time of the stick and created a spreadsheet and Pareto chart. Twenty six percent (26%) took place during or just after drawing blood, 10% during disposal, but 21% of the cases had no description of sub-task involved in the Employee Accident Report. After this the team worked with the managers, Employee Health nurses, and Workers Comp to get all the necessary data.

Contaminated Needle Sticks 8/1/08 to 8/31/09 # and Activity Total 87

Number Percent Drawing Blood 23 26% No Explanation 18 21% During Disposal 9 10% Using Other Hand to Close Safety Device 8 9% In the Trash impacting EVS 6 7% During Surgery or L&D 6 7% After Giving Insulin 6 7% After Giving an Injection 6 7% Removing or adding to an IV 5 6%

Analyze impacts (subtasks, Pareto)

Contaminated Needle Sticks (87) by Activity 8/08 to 8/09

26%

21%

10% 9%7% 7% 7% 7% 6%

0%

5%

10%

15%

20%

25%

30%

After D

rawing B

lood

No Explan

ation

During D

ispos

al

Using O

ther H

and to

Clos

e Safety

Device

In the

Trash im

pacti

ng EVS

During O

R or L&D

After G

iving

Insu

lin

After G

iving

an In

jectio

n

Removing or

adding

to an

IV

With this knowledge Nursing, Laboratory and Respiratory Therapy managers were informed. The team also spoke with Purchasing and learned that their Value Analysis Committee (VAC) is bringing in a new B-D 23G vacutainer needle for drawing blood. This, it is hoped, will greatly reduce these sticks.

Drawing blood was the highest in the Pareto (26%) developed for cases occurring August of 2008 to August of 2009, and now with more information becoming available the team notes that drawing blood remains the most frequent sub-task involved in sticks.


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After the team obtained all the necessary data they were able to determine the sub-tasks involved in the sticks for the first quarter of fiscal year 2010. Going forward all the necessary data will be obtained so that the team can publish the causes and sub-tasks involved to all the managers and stakeholders so that staff gain awareness. The spreadsheet and Pareto chart below shows 10 sticks, or 50% of the contaminated needle sticks that occurred in a 3-month period took place during or just after drawing blood

Contaminated Needle Sticks Q1 2010 # and Activity Total 20

Number Percent During or after Drawing Blood 10 50% After Giving an Injection 3 15% During Disposal 3 15% Removing from box, tray or drapes 3 15% Closing Safety Device 2 10% Syringe in patient's bed 2 10% Device Type Noted 2 10% Insulin syringe 2 10% Pt. suddenly moved 1 5%

Use sub-teams to analyze time and value and risk management The team took on ad hoc members and created a Safe Needle Device Committee who provided needed data, expertise, and prevention information. The team worked with Purchasing and their Value Analysis Committee for several years to locate safe needle devices and needle-less devices. It was noted that the time utilized for drawing blood and giving injections is allotted for whatever is necessary for the patients’ safety and comfort. There is no wasted time. In fact, too many sticks occur when the staff member is rushing. In some cases actual wait time will have to take place to ensure patient does not suddenly move and/or to wait for a confused or combative patient to be at rest. Risk is managed when the care giver takes the time they need to provide their own safety and take care of infection control.

Pareto of Causes of Contaminated Needle Sticks Q1 2010

0

2

4

6

8

10

12

During or a

fter D

rawing

Blood

After G

iving

an In

jectio

n

During Disp

osal

Remov

ing from bo

x, tra

y or d

rapes

Closing Safe

ty Device

Syringe in

patient's

bed

Device

Type N

oted

Insulin

syringe

Pt. sudd

enly m

oved

0%10%20%30%40%50%60%70%80%90%100%

Number Percent

50% during/after drawing blood


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Benchmark other systems

4-Hospital Number Contaminated Needle Sticks per 100 Beds Compared to CDC Benchmark

0

5

10

15

20

25

30

35

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

5

10

15

20

25

30

35

BGMC NBMC IPMC CSMC Benchmark

10-year average = 7 per year

This will therefore be the benchmark Broward Health uses until more recent data emerges.

BGMC Contaminated Needle Sticks per 100 Beds

0123456789

10

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

716 Bed Acute Care Hospital Average 7/yr.

The Broward Health 4-hospital rate (per 10,000 APD) is currently 1.51 which is 82% below this CDC estimated rate extrapolated to be 8.3. Broward Health owns a 200 bed hospital in Ft. Lauderdale (IPMC). They have approximately 72,000 APD per year. (The team divided this by half to match the 100 bed example, or 36,000 APD per year. That is 30 sticks divided by 36,000 APD = 0.00083 X 10,000 = 8.3).

The team conducted benchmarking and researched the literature. In an article written by the Director of NIOSH and CDC “needle stick injuries are contributing to the overall burden of health care worker injuries. Although we do not know exactly how many work-related needle sticks occur each year across the country, estimates indicate that 600,000 to 800,000 such injuries occur annually, about half of which go unreported.” (Rosenstock)

We refer to the Rosenstock article to also benchmark the healthcare job titles involved. Rosenstock says “most reported needlestick injuries involve nursing staff; but laboratory staff, physicians, housekeepers, and other health care workers are also injured. Health care workers outside the hospital setting are also at risk. Others at clinics, private medical and dental offices,

A 2000 CDC study estimated that 385,000 needlestick injuries occur annually in U.S. hospital settings. “At an average hospital, workers incur approximately 30 reported needle stick injuries per 100 beds per year.” Broward Health hospitals incur an average of 7 contaminated needle sticks per year per 100 beds, or 77% below the benchmark over 10 years.

Broward General Medical Center, a 716 bed acute care hospital with a Trauma Center averages 7 contaminated needle sticks per 100 beds; 77% below the CDC benchmark of 30 set in 2000.


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nursing homes, correctional facilities, and in the community, such as emergency medical response workers, are also at risk of exposure to contaminated blood.”

To benchmark the tasks involved, data from two surveillance programs, the CDC National Surveillance System for Healthcare Personnel and EPINet, a project developed by Dr. Janine Jagger at the University of Virginia, provide descriptive epidemiological evidence of how such injuries occur, including under what circumstances, with what devices and during what types of procedures. “The picture that emerges reflects a continuum of risk opportunities throughout the life-cycle of sharp device use involving interactions among patients, workers, devices and the environment.”

“Approximately 38% of percutaneous injuries occur during use, when a needle or other sharp being manipulated in a patient becomes accidentally dislodged. Other injuries occur after use, during cleanup, or in association with the disposal of a sharp device.” (Rosenstock)

Our records show a similarity to these findings when we reviewed the data for the first quarter of fiscal 2010.

Another recently published study funded by CDC examined needlestick injuries in an acute-care community hospital in Greater Washington, D.C., from 1990 to 1998. The study found that implementation of a multi-faceted intervention program led to a significant and sustained decrease in the overall rate of sharps injuries. Annual sharps injury incidence rates decreased from 82 sharps injuries/1,000 full-time workers to 24 sharps injuries/1,000 full-time workers, representing a 70% decline in incidence rate overall.

When the team extrapolated this data Broward Health by comparison had 14 contaminated needle sticks per 1,000 FTEs in 2005 and 12 per 1,000 FTEs in 2009. The aforementioned benchmark from the Washington DC hospital includes all sharps injuries, not just contaminated needle sticks, however. With that information the team counted all sharps injuries, including contaminated needle sticks, for Broward General Medical Center (BGMC) for the years 2003 through 2008. On average, BGMC has 16 total sharps injuries per quarter or 65 per year. BGMC has 2,844 FTEs. That equates to 23 sharps injuries/1,000 full-time employees. This is equal to the 1998 rate at the benchmarked hospital.

The team also benchmarked data from the Canadian Center for Occupational Health & Safety (COHS) and found a table representing calendar year 2000.

Table 1 provides data on the type of exposure by profession. There were a total of 690 reported exposures as of December 2000. Nurses sustained the largest number of exposures (485 or 70% of the total) and needlestick injuries were the most common exposure type (320 or 75% of total).


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Table 1 National Surveillance of Occupational Exposure to HIV : Exposure Types by Occupational Group (as of 31 December, 2000)

Occupation Nurse Therapist/ Technician

Student/ Resident

Laboratory Technician

Physician Other

Number/Type A B C A B C A B C A B C A B C A B C Total %

Needlestick 320 75% 66% 16 4% 47% 21 5% 78% 27 6% 47% 26 6% 62% 17 4% 40% 427 62%

A = number of injuries B = % of this type of injury for this worker category compared with all workers' injuries of this type C = % of this type of injury compared with all injuries for this category of worker

Also from COHS another set of data was obtained concerning the occupation of the healthcare workers exposed to needle sticks occurring in the year between April of 2000 and March of 2001.

Table 2 summarizes the frequency and rates of exposure by job title, with exposure events listed in descending order of frequency. Nurses accounted for 52% of all exposures. However, the nurse's exposure rate per 100 FTEs was only 4.88, a rate much lower than that observed among phlebotomists (42.78), medical residents (20.97), nuclear medical technicians (13.59), sterilization attendants (12.14), or medical specialists (10.06).

Table 2 Annual exposure rates* based on the number of full-time equivalents (FTEs), by job title - Canadian Needle Stick Surveillance Network, 1 April, 2000 to 31 March, 2001

Job title FTEs Exposures Rate per 100 FTEs

Registered nurse 15,282.87 746 4.88

MD (resident) 515.00 108 20.97

MD (specialist) 824.95 83 10.06

Phlebotomist 172.98 74 42.78

Nursing assistant 2,024.21 67 3.21

Other 5,958.75 68 1.14

Clinical laboratory technician 1,862.46 51 2.74

Sterilization attendant 403.79 49 12.14

Housekeeper 1,247.38 53 4.25

MD (general practitioner) 1,319.80 25 1.89

Other technician 325.38 23 7.09

Nursing student 772.55 18 2.33

Medical student 227.00 15 6.61


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Inhalation therapist 309.60 13 4.2

Other attendant 896.30 12 1.34

Nuclear medicine technician 66.22 9 13.59

Radiology technician 576.90 8 1.39

Patient attendant 509.93 8 1.57

Laundry worker 240.86 4 1.66

Total 33,833.90 1,436 4.24

To compare this total nation-wide healthcare worker data to the data from the Washington DC hospital and Broward General Medical Center (BGMC), the team converted the COHS data into a rate per 1,000 FTEs. In this regard the total needle sticks of 1,436 among 33,834 FTEs equates to a rate of 42.40/1,000 FTEs. This is twice as many as occurred at BGMC. Discuss subteam’s preliminary findings The team’s preliminary findings are that the Broward Health system sharps incident rate and contaminated needle stick rate is anywhere from equal to or 82 percent lower than those benchmarked depending upon metric and denominator. Consolidate subteam’s analysis and findings Before determining the impact of contaminated needle stick injuries the team first measured all injuries as defects in the healthcare delivery system. The opportunities for error are one injury per employee (FTE) per workday. The DPMO showed all injuries to range from a low of 453 in fiscal year 2009 to a high of 718 in 2002. Sigma ran from a low of 4.69 to a high of 4.82.

Total Number Injuries V SIGMA Level

Fiscal Year # # Defects per

Unit

Defects per million

opportunities Sigma Rate

Opportunities

for Defects Injuries Injuries Injuries Error DPU DPMO V

2001 1,426,250 1009 0.000707 707 4.69 2002 1,460,250 1049 0.000718 718 4.69 2003 1,497,000 1003 0.000670 670 4.71 2004 1,501,000 1073 0.000715 715 4.69 2005 1,482,500 839 0.000566 566 4.76 2006 1,522,500 864 0.000567 567 4.75 2007 1,605,250 949 0.000591 591 4.74 2008 1,833,500 971 0.000530 530 4.77 2009 1,845,750 837 0.000453 453 4.82


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Broward Health Total Number Injuries Sigma V

4.004.204.404.604.805.005.205.405.605.806.00

2001 2002 2003 2004 2005 2006 2007 2008 2009

Ended FY '09 at 4.82 Sigma or 99.965 % Yield and 0.021% improvement over '01

Total Number Injuries as Defects per M illion Opportunities and Trendline

0100

200300400

500600

700800

2001 2002 2003 2004 2005 2006 2007 2008 2009

Defects PMO DOWN 36% since FY '01 Ending FY '09 at 4.82 Sigma

Trend lines show that the all-injury rate is going in the right direction. Fiscal Year

Data Units Defects

FTEs Total Contaminated

Needle Sticks 2005 5930 86 2006 6090 97 2007 6421 106 2008 7334 113 2009 7383 89

2010 ytd 7383 20 66 SSiiggmmaa PPeerrffoorrmmaannccee:: VViieewwiinngg CCoonnttaammiinnaatteedd NNeeeeddllee SSttiicckk IInnjjuurriieess aass DDeeffeeccttss iinn tthhee SSyysstteemm

WWaattcchh tthhee SSiiggmmaa rraattee ggoo uupp aass tthhee ddeeffeeccttss ggoo ddoowwnn

66VV DDeeffiinniittiioonnss

UUnniitt == oonnee FFTTEE DDeeffeecctt == oonnee ccoonnttaammiinnaatteedd nneeeeddllee ssttiicckk

OOppppoorrttuunniittiieess ffoorr eerrrroorr iinn aa uunniitt == oonnee ssttiicckk ppeerr FFTTEE ppeerr 225500 wwoorrkkddaayyss ppeerr yyeeaarr

DDPPUU == ddeeffeeccttss ppeerr uunniitt DDPPMMOO == DDeeffeeccttss ppeerr mmiilllliioonn ooppppoorrttuunniittiieess

SSiiggmmaa mmeeaassuurreess pprroocceessss yyiieelldd aaggaaiinnsstt pprroocceessss ccaappaabbiilliittyy 6 Sigma = 99.9997% yield

or just 3.4 sticks per million employee work days

The team then compiled the total number of contaminated needle sticks system-wide for fiscal years 2005 through Q1 2010. This data shows that contaminated needle sticks are 10 to 12% of all injuries.


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Total Number Contaminated Needle Sticks SIGMA Level V

Fiscal Year # # Defects per unit

Defects per million

opportunities Sigma

Opportunities

for Defects Contaminated Needle Sticks

Contaminated Needle Sticks

Contaminated Needle Sticks

Error DPU DPMO V2005 1,501,000 86 0.000057 57 5.36 2006 1,482,500 97 0.000065 65 5.32 2007 1,522,500 106 0.000070 70 5.31 2008 1,605,250 113 0.000070 70 5.31 2009 1,833,500 89 0.000049 49 5.40

2010 ytd 457,746 20 0.000044 44 5.42

Broward Health Total Number Contaminated Needle Stick Injuries Sigma V

4.00

4.20

4.40

4.60

4.80

5.005.20

5.40

5.60

5.80

6.00

2005 2006 2007 2008 2009 2010 ytd

Ended FY '09 at 5.40 Sigma or 100% Yield; Q1 '10 at 5.42 Sigma

Total Number Contaminated Needle Sticks as Defects per Million Opportunities and Trendline

0102030405060708090

100

2005 2006 2007 2008 2009 2010 ytd

Defects PMO DOWN 14% since FY '01 Ending FY '09 at 49 DPMO or 100% yield

The data shows the DPMO is going down while the Sigma rate is going up. Step 5 Improve Present recommendations to process owners and operators The recommendations made to stakeholders involved trialing and implementing safety devices, training of staff in those devices, conducting repeated training and awareness of the user errors


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and techniques involved that lead to the sticks. Even after safety devices are implemented user error and technique is the common cause. Review recommendations, formulate pilot or roll out of preventive measures Training and awareness involved new hire orientation and ad hoc information dissemination on the causes of contaminated needle sticks. Slides were sent system-wide and are used in Nursing new hire orientation.

9/09 P. O'Rourke

Prevention of Needle Stick Injuries

• Wear Gloves• Keep OTHER Hand Away from Needle• Use Safety Devices Available• Activate Safety Devices with ONE hand• If Device does not Activate, just Discard as is• Carry ONE sharp at a time for disposal• Avoid Use of Needles Whenever Possible• Use a Needleless Device to Obtain Specimens from all Catheters

Did you know, all contaminated needle sticks are due to technique/user error?

9/09 P. O'Rourke

• Never Hand an Exposed Needle to Another Person• Never Discard Needles into Trash or Drapes• Never Reach into Needle Boxes• Vacutainers are to be disposed with needle• Never try to Overfill Sharps Containers• Assume Soiled Trays/Drapes Contain Needles and Sharps• Get Help Beforehand with a Confused or Combative Patient

Prevention of Needle Stick InjuriesDid you know, all contaminated needle sticks are due to technique/user error?

9/09 P. O'Rourke

Safe Sharps DisposalPrevent Contaminated Sticks

While Wearing Gloves:9 Hold Device in ONE hand

9 Keep Other Hand Away

9 Activate Safety Sheath/button with One Hand

9 Drop Sharp into Container Flap

9 Flip The Flap With One Finger

9 Do NOT Touch Sharps Container

9 Change Out Container When 3/4 Full

Prepare for improved process, run pilot Piloting of safe needle devices and needle-less devices took place over the next 9 years as devices were introduced by our vendors. Training in these devices took place regularly by the Clinical Education department and the vendor representatives. The awareness slides were piloted and fully institutionalized into inservice education sessions. The results were monitored in monthly meetings held by the Safe Needle Device committee and their findings were reported to the EoC Key Group on a quarterly basis.


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Analyze pilot and results We believe that we have successfully met the challenge of reducing contaminated needle sticks, while attending to patient comfort and safety, and reducing costs to Broward Health. Develop implementation plan Utilizing the Gantt chart and data spreadsheets the team presented milestones to the EoC Key Group on a quarterly basis. In 2002 Broward Health trialed the Monoject Magellan Safety syringe, the BD Insyte Autoguard PIV device, the PuncturGuard, and the BD Single-use Vacutainer holder. In 2003 the Blunt Surgical Suture needles and the Twin Pak and Safety Loc Winged Infusion sets were introduced which were later placed on all crash carts.

BD Vacutainer® Eclipse™ Blood Collection Needleintegrated with a safety shield aligned to the bevel-up position.

BD Vacutainer® Safety-Lok™ Blood Collection Setallows you to deliver exceptional patient care without compromising personal safety; needles that can be easily shielded with one-handed activation.

BD Vacutainer® Pronto™ Quick Release Holder is in compliance with the OSHA Safety Health Information Bulletin for Phlebotomy which recommends single use of blood tube holders.

BD Safety-Lok™ blood collection and infusion set with luer adapter; transparent shield is moved over the exposed needle and locked into protective position.

In 2005 the team implemented the BD Retractable Infusion sets, the BD Safety Glide TB and Insulin syringes, and reviewed and trialed safety scalpels and various sharps disposal containers. In 2006 Tyco sharps disposal containers were agreed upon and implemented completely in early 2007.

Cost savings emerged in that the team showed Broward Health an annual savings of over $12,000 at just one hospital by utilizing the BD saline flush sets. In 2009 a new18g blood culture needle and adaptor were introduced, a new safety insulin syringe and new 25g vacutainer needle were introduced successfully.

In 2004 the Safety Huber needle for pediatric and adult populations, the BD Retractable Safety Infusion set, the Kendall Blood Culture bottle adaptor, and Pre-filled saline/heparin flushes were introduced, and the Kendall Transfer Sets for blood cultures, and the BD protected blade system were trialed.

In early fiscal 2007 the team piloted and implemented a BD Protected Blade system in several Operating Rooms and obtained new Contact-activated lancets from BD.


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The Stericycle Biosystems reusable sharps container program was begun in the first quarter of 2010. This provides a reduction in waste to landfill and removes the responsibility of changing out full sharps containers by the Environmental Services staff. Present final recommendation to management team Presentations were made to the EoC Key Group on a quarterly basis and the team presented their findings using the 6 steps to Six Sigma: Project selection, define, measure, analyze, improve and control (PDMAIC) at the Broward Health Corporate-wide Quality Expo in January of 2009. Step 6 Control Display results and define control metrics and processes Controlling the exposures to contaminated needle sticks is assured only by institutionalization of the policies and procedures established by the performance improvement process. The team and management are committed to making sure safety devices are in place and utilized. The team will continue working with the Purchasing Department VAC, Value Analysis Committee regarding new devices as they become available. Continuing the training and awareness in classroom and online programs is critical to quality. The Safety Officers, Workers Compensation and Employee Health Nurses will constantly observe, track and report all sticks and their cause and source. The rates are reported quarterly at each of the 5 regional EoC Committees and to the Key Group. Contaminated needle sticks are treated as defects in the healthcare delivery system and the rates are presented in occurrences per 10,000 adjusted patient days at the hospitals, per medical encounter in Community Health Services and in Six Sigma terms.

Number of Contaminated Needle Sticks System-wide

020406080

100120140

FY '05 FY '06 FY '07 FY '08 FY '09 FY '10YTD

Cost per Stick and Trendline

$0.00$250.00$500.00$750.00

$1,000.00$1,250.00$1,500.00

FY '05 FY '06 FY '07 FY '08 FY '09 FY '10YTD

The number of sticks went down 21% FY '09 over FY '08, but the costs went up 29% over FY '08 due to treatments for HIV and lost time.


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4-Hospital Number Contaminated Needle Sticks per 100 Beds Compared to CDC Benchmark

0

5

10

15

20

25

30

35

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

5

10

15

20

25

30

35

BGMC NBMC IPMC CSMC Benchmark

10-year average = 7 per year

Broward Health Total Number Contaminated Needle Stick Injuries Sigma V

4.00

4.20

4.40

4.60

4.80

5.005.20

5.40

5.60

5.80

6.00

2005 2006 2007 2008 2009 2010 ytd

Ended FY '09 at 5.40 Sigma or 100% Yield; Q1 '10 at 5.42 Sigma

Sigma rate went UP from 5.31 to 5.40 in FY ’09 over FY ’08.

Total Number Contaminated Needle Sticks as Defects per Million Opportunities and Trendline

0102030405060708090

100

2005 2006 2007 2008 2009 2010 ytd

Defects PMO DOWN 14% since FY '05Ending FY '09 at 49 DPMO or 100% yield

The contaminated needle stick injury rates are on the corporate Dashboard that goes up to the Board of Directors and the QAOC, Quality Assurance and Oversight Committee. Metric: Contaminated needle sticks rate per 10,000 APD: DOWN from 1.99 to 1.33 or 33% in FY ’09 over FY ’08.

Defects per million opportunities went down 14% since FY ’05 from 57 to 44 DPMO. Q1 2010 at 44 DPMO or 100% yield in process capability.

The CFO has asked for quarterly cost savings metrics in the Environment of Care and the cost of contaminated needle sticks is one of those metrics. Metric: System-wide reduction in cost of contaminated needle sticks: DOWN 56% or $28,409.00 in FY ’08 over FY ’07, but UP 29% fiscal year-end ’09 or ’08 due to treatments and lost time.


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References

Canadian Centre for Occupational Health & Safety January 25, 2005

CDC National Surveillance System for Healthcare Personnel Infection Control and Hospital Epidemiology July 2007 Jagger, Janine, PhD EPINet, University of Virginia, National Safety Council Pyzdek, Thomas and Keller, Paul. The Six Sigma Handbook, third edition. McGraw Hill 2009

Rosenstock, Linda. STATEMENT FOR THE RECORD ON NEEDLESTICK INJURIES National Institute for Occupational Safety and Health Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. June 2000

black belt final projectporourke copy 2

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