Organisational Challenges and Change Implementing safer needle devices in Newham University Hospital NHS Trust, London Ann Colohan Occupational Health Advisor

Introduction to Newham University Hospital  Situated in East London between Tower Hamlets, Barts and The London and Redbridge NHS Trusts.  University hospital Trust has 550 beds  Most ethically diverse area in the UK –with 110 languages spoken in the community  Over 40% of the population is in the under 25 age group  The London Borough of Newham has the highest number of families affected by HIV/AIDS, compared with national rates of HIV(Oker, C 2000)  In-house OH Service, providing range of services including a lead role in the management of NSI

Introduction  Aim: To give an outline of the processes Newham undertook in order to introduce safety needles throughout the Trust in Occupational Health were already aware of problems surrounding needlestick injuries prior to Many injuries were occurring downstream particularly in relation to inappropriate disposal of sharps -A change was needed in order to reduce the risk of blood borne virus exposure and reduce the incidents of needlestick injuries

 In 2001 a business proposal was sent to the Trust’s Executive Management group outlining a case to introduce safety needles in all areas throughout the Trust  The decision was taken by Senior Management by the end of 2001 to adopt the proposed upstream programme of injury prevention and support implementation of the identified safety needles  This is our journey…..

Implementing Safety Needles – Year 1 (2000) The first year was primarily about collecting data & identifying any trends Collecting Data  Information was gathered about UK & International attempts to reduce the risk of sharps and needlestick injuries: literature search, conferences, sharing experiences with colleagues  Meeting with Trust staff, managers, speaking to staff who sustained injuries & union staff. Asking staff for their opinions, ideas and their perceived needs

Identifying trends  We continued to monitor needlestick injuries  Data from all reported injuries in 2000 was collected and analysed and results of the audit were included in the 2001 report.  It was found that approx 40% of needlestick injuries in 2000 were attributed to cannulation or venepuncture needles. Surprisingly only 7% of these injuries occurred during the procedure 33% of injuries had occurred after the procedure, raising concerns about the reasons for this (see graph).  Due to the high risk of blood borne virus exposure 14% of injured staff required Post Exposure Prophylaxis  Numbers of injuries were found to peak soon after each new doctors intake  An audit of clinical practice in 2000 revealed only 14% of staff had opted to use a vaccutainer system during phlebotomy procedures– inadequate supplies, preferred using a needle & syringe, not confident using vaccutainer system.  It was also found that 57% of staff carried their used sharp (in a receiver tray) back to a treatment room to dispose of the sharp  3 Areas of main concern – type of needle (high risk) causing injuries, training of existing & new staff and ensuring adequate supplies of equipment

Year 2 (2001)  Next stage was to define actions needed to be taken  Risk Assessment  Priority was given to practices that carried a high risk of BBV transmission –safety products that would reduce high risk injuries were considered  Meetings were set up with various companies to discuss products, training needs, ongoing support and arrange trials of products  Communicating to staff began-consulting & persuading staff, developing a working group (supplies dept, lead nurses, PDN’s, Infection control team, A&E staff, Theatre staff, Phlebotomy staff, H&S) co-ordinated by OH  An audit of clinical waste bins in 2001, highlighted concerns which contributed to some injuries  The Business Proposal  The proposal showed how 57% of injuries could have been prevented by introducing various safety needles  It proposed to prioritise equipment –I.e. procedures that carried a high risk of exposure to BBV through needlestick injuries  It included a financial breakdown of costs of introducing safety equipment and results of evaluated trials of safety equipment

Breakdown of cost of injuries  Low Risk Injury  Initial Assessment – nurse time away from the ward/dept OH nurse advisor time Treatment given – hepatitis B booster, bld test Laboratory costs – blood tests, laboratory staff time Counselling time –one session Completion of incident forms & accident investigation – management time Estimated cost of a single injury - £245 High Risk Injury Also included costs: 4wk course of PEP treatment Additional follow up appts, blood tests, counselling etc Estimated cost of single injury - £1,200 Cost comparison Cost of current equipment (cannula & phlebotomy equipment) & cost of injuries 2000 were estimated (excluding consequential/hidden costs e.g. agency staff/litigation costs/psychological effects/reduced morale/retention of staff This was compared with the cost of using safety needles throughout the Trust – found to be a more expensive option

Year 3 (2002)  Implementing safety needles  Following a discussion of the proposal, senior management agreed to support an implementation of safety products throughout the Trust agreeing to fund the extra costs of the equipment until the new financial year.  Agreed timescale – 3 months Jan-March 2002  Key staff were informed (working group) of the proposed plan and preparations were made with the product company for training, roll-out & supplies of safety equipment  Plan of the implementation was communicated to all staff  Training of staff: Existing staff Jan-Feb New doctors Feb (induction week)  Company trainers aimed to ensure maximum numbers of staff were trained within this period and training would be cascaded to colleagues who were unable to attend (agency, part time, night and weekend staff)  Time was allocated for troubleshooting any further problems  OH took a more pro-active role in presenting needlestick injury reports & discussing safety issues to new doctors and during staff induction  Following the result of the sharps bin audit, all wards & depts were equipped or advised on suitable sizes and numbers of bins and appropriate trays to carry bins to the patients’ bedside.

Lessons Learned  Communication is paramount. Use as many ways of communicating as possible, allow for those who do not read s or circulation letters  Agree your cohort carefully. Ensure they are the biggest users of the product & that they will co-operate with evaluating the product to provide a true picture of their preferences & any unforeseen problems  Ensure total commitment from your working group. Form the group early-they will help with the change process, help to predict downfalls and support one another  Evaluate the product after implementation-checking for technical or user problems & needlestick injuries- as improper use can lead to increased risk of injuries  Be ready for resistance to change & listen to staff concerns

Year 3 (2002)  Only 50% of our work was welcomed initially..  Venepuncture equipment was an instant hit!  Cannulation needed a bit more persuading and a lot of extra training

What has changed?  Total number of reported injuries increased initially – hence improved reporting  Cannulation & venepuncture needles causing injury 2000 –40% 2002 –reduced to 1.8% 2004 – 9%  Staff requiring PEP following an injury: 2000 – 14% 2002 – 6% 2004 – 9%  Change of trends

In 2000 it was found that almost 40% of injuries were attributed to cannulation & venepuncture needles. With the introduction of safety needles there has been a marked change in this trend.

Next Steps  It is evident that safety needles alone will not reduce the incidences of needlestick injuries. A risk assessment of the problem needs to be undertaken as a primary step in order to understand the risks and trends occurring in individual Trusts. Once this has been identified it is easier to build a business case on introducing safety needles.  Continued support is required from Senior Management and staff at all times –it is important that cost is not a barrier to implementation  Once staff at Newham seen an improvement in practice and injuries as a result of safer equipment, they expressed an interest to try something new again. –a change of cannulation device & safety blood gas syringes..