Good afternoon, everyone. I'm Maria Lonzi. I am an adult nurse practitioner and program manager for the Corporal Michael J. Crescent VA Medical Center in Philadelphia VA. And you are in, oh my God, I just had a needle stick, a lecture for today. So I am here presenting with my colleague, Arlinda Singh-Draha, who is also a nurse practitioner for the Phoenix, Arizona VA. And today we're going to be talking about how both of our facilities were able to change culture and institute new processes, as well as some standardized efforts for collecting data to be able to decrease, A, the number of needle sticks, and B, the amount of HIV pep that's been dispensed. Since we both work for VA, we have to read this disclosure. So please, we have no actual or potential conflict of interest in relation to this presentation. The opinions expressed in related educational content are our own and do not necessarily reflect the formal opinions or recommendations of the Veterans Health Administration. And we are solely responsible for the content of this presentation, including copyright and other intellectual property compliance. We have a couple of objectives, and we'll just get those out of the way. We're going to describe the key aspects of a bloodborne pathogen exposure control plan. We're going to identify the role of employee occupational health in reducing bloodborne pathogen exposures, how to best integrate processes across departments to achieve improved outcomes, and we're going to describe some best practices for data collection and management. So I have approximately 38 years as an adult nurse practitioner, board certified since 1985, and I've been in OccHealth for over 15 years, and I think it's the greatest specialty going. And I'm very grateful that you guys invited us to present this. I've been dealing with bloodborne pathogens now for probably that amount of time and did some of the first studies with NIH on HIV transmission in the early 80s. So we'll go to him here. What we do know is bloodborne pathogen exposure remains a critical risk for all of health care personnel. And in a given year, we're estimated that there's over 400,000 needle sticks, and that occurs just in a hospital setting. We are not talking about what happens in an outpatient clinic, in a physician's office, in an urgent care center. This is just purely within a hospital setting. The highest risk of exposure remains nurses, with about 44% of all the exposures occurring in the nursing population, and the OR accounts for about 40% of all the needle sticks. Inpatient units are about 25%, and the greatest hazards that we can talk to you about are after use and before disposal. So people that are trying to engage safety or if a patient moves during the procedure, things like that happen. We know as much as we would all like to very much have zero needle sticks, that in my lifetime that's probably an unrealistic expectation. The 2020 EpiNet data will also support what we have just looked at, and so that we know again that 43% of injuries occur in the operating room, and that 26% occur within an inpatient setting. And what we do know is that the most frequent injuries occur sutures, and that is primarily an issue for our clinicians, particularly surgeons in the OR, who will have a high degree of suture sticks. And disposable syringes account for about 16.7% of all the needle sticks. And then the blood collection wing needle or butterflies are also difficult, and we find a lot of times in our practice that a lot of that has to do because the patients move as we're pulling out the butterflies. Within the data, we wanted to mention splashes, because we did notice some really obvious data change during COVID. Splashes, what we recognized before the 2020, because we mentioned that this data is based on older data from about 2018 to 2019, is that only 12% of your healthcare personnel were wearing any sort of eye protection. During COVID, what we did find is that we had a major decrease in the number of splash occurrences, because everybody had on eye protection. And so we're going to be working on a paper for that later on in the year, but it was a good test of eye protection does save you, please wear it. The economic and emotional burden, I'm sure you're all familiar with. It has a $3,000 or more per needle stick, but that has to do primarily with just the actual direct cost of the sticks. It doesn't account for lost days of work, nor does it account for the emotional instability that occurs when a patient has a needle stick. Oftentimes, you'll have a healthcare provider or a clinician coming to your office and really upset. They're usually very young, at least in our setting, because we're an academic teaching facility. They have their first needle stick, they don't know what to do, and they all think they're going to die. So the amount of fear and anxiety is off the charts for them. And the other piece that is not accommodated for in these numbers is the long-term effects of if you give somebody HIV pep. So recognizing all of that, in 1991, OSHA issued the bloodborne pathogen standard, which everybody in this room knows about, and everybody in this room probably lives and dies by. And it was in response to the global concern. So prior to 1991, I was in practice, and we did not have a bloodborne pathogen standard. And the real response to global concern was not, was the transmission of disease, but was really because of the AIDS epidemic. And people were so afraid of getting AIDS from needle sticks. So OSHA recognized this concern. It said, okay, we need an interdisciplinary team. That team has to work together. You have to figure out how to reduce and eliminate any exposure to infections. It includes in that standard, and we'll talk about that later, it talks about hepatitis B and HIV. It doesn't specifically mention hepatitis C, but we know that we now have that in place. Just so that you're all aware, there are other standards that also govern our practice. One is the personal protective equipment standard, which I'm sure after this last two years, we're all very well familiar with. And then the current standard for safety glasses for Mansi. So OSHA, between 1991 and 2000, realized that there are more issues with the percutaneous sticks. And so the Needle Stick Safety Prevention Act, signed in 2000, actually gave bigger teeth to the OSHA bloodborne pathogen standard. It meant that you had to recognize that having a needle stick is the highest risk of transmission. So it mandates employees to provide safety engineer devices to anyone that's at risk of a bloodborne pathogen exposure. You have to engage your frontline workers in selecting safety protective devices. And you, as the employer, must review the bloodborne pathogen exposure control plan at least annually. And you must explore, at least annually, new SHRPS technology. So you can't just be riding along and just keep using the same needles and the same butterflies and, oh, somebody has something new, but you didn't know about it. You need to know about it. And the big piece for us is maintaining a SHRPS injury log, which we all know, which is basically any exposed health care provider, personnel, and the source patient, making sure that they're not in the medical record and that you have followed up for your employee. The exposure control plan is written. It has all the elements of the bloodborne pathogen standard. So please, if you don't have an exposure control plan, hold the standard. Make sure that your exposure control plan meets all of the requirements. It includes all of your areas of your facility, all of your satellite areas, all of your research areas, all of your clinics. And it has to be available to all employees. And again, as I said before, you have to review it and update it annually. And in Philadelphia, we do that as a group. Infection Control, Safety, and AHK Health reviews the exposure control plan on an annual basis. AHK Health's role is really one of helping to identify which jobs in the facility are at the highest risk or have any risk of a needle stick or a potential exposure. And within that, we must make sure, and I'm sure you're all familiar with Category 1 and Category 2 employees for Hepatitis B, that the Category 1, everyone gets offered Hepatitis B, but you really have to make a concerted effort for those that are Category 1. And they should be offered free of charge Hepatitis B within 10 days of being assigned to any risky environment. So for example, if you have a housekeeper who for the most part is just cleaning offices or outside garages and now is going to be assigned to the OR, within 10 days of their assignment to the OR, you have to make sure that they understand the risk of contracting a disease and you have to make sure that they have been offered a Hepatitis B vaccine. And OSHA says it's a mandatory opt-out. So if they wish to decline that vaccine, that is fine. They have to sign a declination. It does not mean that they cannot come back at a later date and say, I have decided to get that vaccine. In our clinic, we have both nurses and myself, and we do religious education for most of our workers that are in Category 1, particularly among EMS workers and workers that are med techs circulating in the OR. You have to identify and ensure the use of safe work practice controls, meaning that you have to know what they are and you have to make sure that they are being used. It doesn't mean you have to walk around every day and bang on somebody's door, but you need to be aware when you have a needle stick, like if somebody wasn't following this, you don't have a safety needle device, like that's not okay. I chair the SHROPS task force, so when I'm seeing these patients or when they come to AHRQ Health, I'm immediately notified, we immediately notify our team, and then we start addressing the issue of why perhaps there was no safety device in that area. Again, explore changes in technology. AHRQ Health is also involved in selecting, not providing, that's my industrial hygienist people, but we are involved in selecting the amount of personal PPE and what kind it is, and we make sure that it meets the ANSI standards for goggles and that it is fluid resistant as well. We are also responsible for helping develop signage for people, and we have to remember about handling biohazard waste and how people decontaminate equipment, and again, the people that are involved in those processes also need to be made aware of the availability of hepatitis B, and we provide hazard communication and training, and this has to be initially in person and yearly, and you have to offer your employees, has to be interactive, they have to be able to ask questions. So in AHRQ Health, we do it once a year at our new employee orientation, and then we have an educational model as well, and then they are given questions, they can come to our department and ask any questions that they want, and they're always invited to after a NEO. And so the elements, maintain an employee medical and training records, so those training records are maintained by our education department. Every employee that has a potential risk exposure, you need to make sure that they have been trained in the proper use of that device, as well as have been trained in how to avoid needle sticks, and have been given the opportunity for hepatitis B, and that is all documented in our processes and maintained by education. And then we have to have a system for reporting exposures and providing post-exposure evaluation and follow-up, and so I will talk about that at the next session. Our Linda is going to take on from here. We don't have any sound, so our IT guy, are you checking if there's no sound so far? Can you hear us now for those attending virtually? Wonderful. Resounding yes. So good afternoon everybody. It is a pleasure for us to join you today. My colleague Maria Lanzi and I is excited to share with you some of the work that we've done. I am from Arizona, so I brought a little bit of sunshine. For the past three weeks I've been monitoring the weather because we are actually at 90 degree weather over in Arizona, so a significant drop when I had to fly my flight down here, had to bring my winter clothes again. So I am an adult nurse practitioner. I've been in the field of occupational health specialty since the early 1991. My background during that time is that if you're not a nurse, if you don't spend time in the hospital setting, so I certainly made sure that I spent my time in occupational health setting, and when I saw our patients in the step-down unit, the burn unit in the ER, we have a lot of preventable injuries, and I can change a patient's name, but the evidence practice of medicine still stays the same, right? So in retrospective, I said what would be the best specialty we're in? I can take care of myself. I'm short. I deal with orthopedic patients who came from the OR, and I cannot continue to manage them when they have post-operatively with a knee replacement, and I had the opportunity to work for a semiconductor company, and I fell in love in occupational health medicine. You never know what walks in your door. It could be a chest pain. It could be a diabetic emergency. It could be a hydrofluoric acid exposure, and yes, that was one of my experiences. I'm going in, and so I fell in love with the specialty, and I've grown in my role. I've worked in semiconductor, and I told one of the site managers that we need to have an in-house occupational health program versus outsourcing it. I was spending close to a quarter million dollars for an organization off-site to provide that services, and hence they said we're not in the business of health care, and I said that was the wrong answer, so I left and got my adult NP. So the role, moving back to blood-borne pathogen, Maria shared with you one of the key things of blood-borne pathogen, how it started, what was the emphasis, the economic and the emotional burden. I still remember my first patient, who was a child-bearing intern when she had her first needlesick injury, and the tears, just the fear coming down. You can see in her face, so I strongly believe that a lot of your injuries are preventable, and if you work hard at it, if you work with other departments within your organization, you can reduce the injuries, and I'm hoping that our outcomes at the end of the presentation will highlight that there's a lot of work behind it though. So very good. So what is our role in occupational health versus nursing, our occupational health medicine, and Maria had alluded to the key elements of the BPP exposure control plan. So my job then going into an organization is identifying who the key players are, identifying what the key roles and responsibilities while staying within my swim lane. So for example, when I used to work for a leading aerospace company, I used to, we own the BBP program, and we update the ECP every year, and request from our end users, are there better engineering devices out there? But when I switched to the VA, I then had to ask my chief who owns the Bloodborne Pageant Program, and what are our delegated roles and responsibilities, because I want to make sure that I stay within my swim lane, that I respect people's responsibilities, and there's no crossover. So the key role in our respect was that I was able to consult with the IC, with the supervisor, with the manager, and identifying what are the key jobs or classifications of job that places people at risk for bloodborne pageant exposure. Maria alluded to of the category one, these are your workers who are at high risk of bloodborne pageant exposure inherently by just their job classification alone. So these are your surgeons, the physicians, your phlebotomist, your nursing staff. And category two are those that workers that you don't expect that there's a potential for high-risk exposure of bloodborne pathogen. However, they may be called upon. So for example, your food service worker who may be asked to respond to an emergency. And with the offering of the Hep BV vaccination, we know that vaccination, for those of you that attended Dr. Osorio's, the class at 216 mid-morning, he had a great overview about primary prevention strategy. And vaccination is considered one of the primary prevention strategies. And hepatitis B vaccination has been proven to provide about 90% efficacy, so that had helped reduce the transmission of Hep B among healthcare workers. She alluded to that it has to be mandatory for you to be able to provide hepatitis B or offer hepatitis B vaccine to your employees at least 10 days within the initial assignment or the possible exposure to OPIM or other potentially infectious material. The new employee need to sign off or that they've declined the Hep B vaccination. At a later time, they may come back to you and ask for the Hep B vaccination. With the BBP standard, it mandated for us providers to provide written evaluation within 15 days of exposure. And my next slide will further discuss this in detail. And as occupational health, we are responsible and the custodian of the medical records of that employee at least 30 days during that employment and beyond. Thirty years, sorry, 30 years. So we are responsible for protecting that health information. For the maintenance of the sharps injury log, the subpart C of the OSHA record keeping standard dictates what are the prerequisite of maintaining the sharps injury log. The basic premise and what we need to understand coming out of this session is that one, it has to be documented on the OSHA 300 log. For those of you that are responsible for record keeping, keep that in mind. And at the same time, you need to maintain the employee's privacy. You cannot document the employee's name into the log. So within the standard, we are mandated that as employer, we have to provide post-exposure medical evaluation and follow up in a confidential manner. So for our operation, we're a Monday through Friday operation after 5. Our emergency room providers are the backup for us. So if you're an offsite facility, I know I've met quite a few of you. If you think that if you're aerospace or transportation, I don't have to deal with blood, bone, pancreas and exposure, that is wrong. Because guess what? You're going to have a housekeeper coming into your clinic saying, I was emptying or I was reaching over a drawer and your co-worker just resigned and left an insulin syringe. So that sores it unknown. So you will have the potential that you're going to be faced with as a healthcare provider on how you're going to manage someone that was exposed at the needle. So before you put yourself in that position, I would certainly recommend that you work with the closest ER that are experienced in post-exposure prophylaxis and set up protocols. How you're going to communicate to that receiving ER urgent care. You need to provide that receiving ER or urgent care, the job description of the injured employee. You may need to be knowledgeable of the OSHA standard. They need to communicate back to you confidentially the employee medical records. And that medical record has to be kept in the employee file. The other elements of that documentation should include the route of exposure. Is it a cut, a clear, clean cut with a scalpel or is it a hollow-bore needle? And how deep is the cut? The collection of the employee's baseline HBV, titer hepatitis B virus, HCV and HIV. And as Maria alluded to, the BBP standard only speaks to us about the HBV and HIV, but we know that we need to be looking for post-exposure for HCV. And if we know who the source individual is, we need to look for the hepatitis B surface antigen, baseline hepatitis C and HIV. And that result has to be made available and be reported or communicated to that exposed employee in order for you and that employee to have a shared decision-making in terms of having to start them on HIV prophylaxis medication. Then certainly with the counseling, what happens if you're waiting for the test result? What would they need to do? And certainly an evaluation of related reported illnesses. So within the realm of workers' compensation, if it was a work-related exposure, you want to start educating that injured employee. What is your internal process of starting to file an OSHA-reported injury or your internal safety investigation and how to initiate an investigation? And what would be the repercussion if that source patient is HIV and they develop an HIV, tested positive for HIV, what would be their next option of filing workers' compensation? Since the advent of the VVP standard and the, which forced their vision of the VVP standard in 2001 and the NSBA, due to the NSBA, we've seen a decline in the SHOPs injuries from close to 40 for 100 average daily census down to 100 in 2015. However, nurses continue to be impacted in a large proportion related to SHOPs injuries. Contaminated sutures and cast scaffold blades certainly to be very high among our physician group. And I will tell you, this data reflects what I'm seeing in my organization and it baffles me. And for those of you that have some ideas how we can minimize or how can I minimize, I'm telling myself, how can I minimize further reduction in exposure to my surgeons, I welcome you. I have yet to find out whether there's simulation suturing lab out there that maybe are dermatology interns or podiatry interns, that's where we're seeing a lot, that they have a lot of exposures to sutures and scaffolds. And certainly approximately 25% of all injuries are from the non-use, such as your laundry worker, your EMS worker that's helping disinfect a room or empty garbage and whatnot, so. Same pattern, what we've seen with hepatitis B infection, there's been a decline due to the offering of hepatitis B vaccination, which is a mandate under the standard. Occupational exposure to HIV, we've seen a reduction. There's only one documented in 1999. This was a seroconversion. But certainly, we can never stress enough that the importance of getting the source tested to understand what their HIV status is and offering HIV prophylaxis is the key thing in reducing the transmission of HIV. This lecture, we're not talking about what should you do, what are the first line, there was a gentleman who was in the late morning session that talked about are there any guidelines out there. I subscribe to Hippocrates, that's my bible, and there's always an update to that. And the CDC guideline talks about what would be your prophylaxis for non-occupational exposures, as well as for occupational exposures. And it's up to date since they have it updated in 2018. What's alarming, though, was in 2014 to 2016, this is the data from the International Safety Center, this is where 1,500 hospitals within the U.S. uses EpiNet. And what's alarming, even though with the mandate of the NSP in 2000, we're seeing a lot that only 31% use a safety device. And we've got a lot of work to do. This is where it's so important to go back to your workplace and say what is our mechanism of communicating back to our end users if there are better, safer devices out there, right? And only 60%, 60% are not engaging the safety device, and I see that a lot, or inappropriately engaging the safety device. If you look at the standard, it says when you engage a safety device, it's supposed to be one-handed, not two. So there's that potential that as I hold my device and try to engage, I accidentally poke my finger. Or I've had staff that they would disengage the device with their chest. So, I mean, it doesn't matter whether you're an experienced surgeon, or a nurse who's been in the ER for 25 years, or once a new grad in a year ago. I've seen that they have the risk for exposure. We are the leading experts in occupational health, right? Our job is to optimize employee's health, protect, maintain. Oh, thank you. Oh, I do apologize. Yes, thank you. So as I mentioned, we are the leading experts in protecting employee health, in optimizing employee health. OK, I'm fine. And so we're responsible in preventing and managing occupational injuries and illnesses. We're promoting safety, shifting the culture to our safety-based culture, right? I have yet to work in an organization where, and we can document in our performance plan, one safety goal for that employee. Not just taking my safety training yearly, right? There's got to be something more beyond just making sure to take my safety training. And I think that would be one of the best ways to move towards a safety-based culture. But in my practice, I use the public health, primary prevention, secondary, and tertiary prevention as the framework when I start an organization and hopefully work towards the desired culture wherein I spend very few hours doing secondary and tertiary prevention, but going out in the field, going to the boiler room, going to the EMS laundry department, making sure that the risk has been minimized so I don't have repetitive injuries, that I don't have any sharp injuries from my laundry workers. So that is the desired culture that I would like to move into. And yes, I do believe that I think we can further reduce the onset of blood to infection exposures. Looking at the health and wellness continuum, on my right, if you have an employee that has an optimized health, we know that this employee will be very engaged at the workplace. They will have employee morale. They have increased productivity, certainly have identified near misses to reduce the exposure to bloodborne pathogen or any other safety issues that would occur at the workplace. We would reduce our medical costs related to workers' compensation. On the other side of that continuum would be your illness model, wherein when an employee is ill, you've got employee morale. They don't want to come to work. They have increased lost workdays. They've got increased workers' compensation. They come to your clinic, and you kind of get to know them many, many times, right? And so what we have to do is we need to minimize and reduce workplace hazards. You've seen the slides. I know you've seen it, because I've seen this around some of the presenters during the conference. NIOSH identified hierarchy of controls. On the very top are the most effective, and on the very bottom are your least effective. And oftentimes, your most effective are the ones that are most cost effective, depending on the return on investment that you're looking at. The very top is you want to eliminate the hazard. And again, I'm not a surgeon, certainly, but they know their job more than we do. Can they eliminate the hazards? Certainly some procedures that they can do robotics versus going in, and there's a lot of advancement in medicine. We want to substitute the hazard. I don't think we can do that with blood-borne pattern exposure, but certainly from an engineering control, using safety devices, getting your staff engaged in making recommendations. During our new employee orientation, where employee health is one of the presenters, and I tell my new employees is that you have a new set of eyes going into the organization. You have the opportunity to make some changes within your organization, because you know your job more than I do. So I do welcome you to approach your infection control staff, your manager, employee health, and make some recommendations. And I've seen them a lot. We've made some revisions with our catheter that's used on hemodialysis, because of new nurses coming in saying there are better, safer devices out there. And in terms of administrative control and our PPE, so there are ways to reduce the hazards within the workplace. Turn this over to Maria. So the next case, the first case that we're going to talk about is Maria will be sharing with us the outcomes of her process improvement within her facility related to minimizing, reducing the dispensation of HIV prophylaxis. Thank you, Iralinda. Really appreciate that. So in 2016, I took a new job, and it was in the Philadelphia VA Medical Center. And if any of you have gone through the Philadelphia or any VA medical center, you'll know that each VA is its own entity, even though it is part of an incredibly large organization. And that moving that is sort of like trying to move the Titanic off the ocean floor. So I came in as this fresh, loving Ahmed coming from the private sector. We can do better. Let's come into the VA. And what I realized, my former colleague, who was a nurse practitioner before me, handed me and said, great, you're in charge of the SHARPS test for us and all the blood-borne pathogens. I said, OK, great. Let's just take it, and we'll run with it. And what I did, I'm very data-oriented. And I was looking at the rate of data. And I was looking at the rate of sticks. And I was looking at the rate of encounters. And I was looking at who had splashes, who had needle sticks. And what I realized, and being the VA, let me preface this by saying occupational health does not have an electronic record. We are on paper. And we have data going back to the 1990s all on paper. So medical records are a paper blue chart. Blood-borne pathogen exposure records are in files that occupy, I'd say, at least that wall. And they are not in the employee records, other than a notification that they had a needle stick. And so it was a really daunting task to look at the data. But as I was going through the data, I realized the same culprits kept coming up. And we had specific high-risk departments over the years that didn't change, dentistry, podiatry, surgery, and dermatology. And then the other thing that we realized, or I realized, was that, why is it taking so long for me to get my results back? I don't understand this. I'm sending this patient to the lab. They go up. We grab the source blood. They go up to the lab. They get the blood drawn. Why is it taking me three days or four days to get the lab result back? This makes no sense to me. And the biggest thing for me was that my employees were really stressed out because the Philadelphia VA has 30% rate of hepatitis C-infected patient population. And so they were stressed out by that. ID was constantly being consulted. And HIV PEP was dispensed on a routine basis, primarily to offset the anxiety of the employees, even though we know that there are toxic effects from the HIV PEP. So I looked at all this and said, this isn't making sense to me. What I did was a root cause analysis. And what I realized is that every service in the hospital had a different order for source blood. And Ock Health and ED had different orders for an exposed employee. I also realized that the ordering clinician who was ordering HIV PEP in the ED was really moonlighters and didn't have a great deal of experience with needle sticks nor with how to dispense or order HIV PEP. And granted, they're dealing with heart attacks and gunshots and everything else. I get it. And then the other piece that really bugged me more than anything was that it took this inordinate amount of time for me to get a source blood back on a patient that's in-house and the lab was drawn. And there were multiple issues that were involved here. For example, nurses in the VA in Philadelphia cannot accept a verbal order. And nurses in most of the places in the departments do not draw blood, so the lab techs have to come and draw bloods. And if you don't enter the order correctly and make it a stat order, the lab tech's not coming until the next time those labs are ordered on that patient that's in house. So there were a lot of little pieces that I had no idea was causing all of these issues regarding needle sticks. And since I was A, neither in the military, B, my first time in the VA, I had no idea that there was a chain of command that you're supposed to go to when you want to make a change. So what I did with some of my colleagues and a wonderful medical student, Jillian Smith, is I designed a new standardized ordered set. And I decided for the source patients, we're going to draw a hepatitis B surface antigen. We're going to draw a hepatitis C antibody. We're also going to draw a hepatitis C RNA or a viral load. Being in the VA, we have that kind of access. Instead of drawing regular HIV antibodies, we're going to get the new P24 test so that we can have this result done rather quickly and be very secure in what our results are saying. We designed this order set for the source patient. And then we designed an order set for the exposed employee. And in the VA, you had to order your orders separately. And so what I did was decide that one should be order set number 22 and one should be order set number 23. And so we just named them order set number 22 and order set number 23, and in parentheses saying what they were for. We then went up to the lab. And we didn't really talk to the chief of the lab. We instead talked to the people that were drawing the blood as well as the front desk people that check in both the source patient and the exposed employee and did an education session to explain to them why this is considered an urgent matter. And that while you have 50 vets sitting waiting for blood, that if somebody comes in and said, I just had a needle stick, they have to go to the front of the line. And their lab has to be pulled from the line and accessioned immediately. So the third thing we did was get pharmacy involved because we realized that a lot of the ED docs didn't know how to order HIV PEP. And so we created a standardized HIV PEP order set that would be available to them. And then because of off tour, and the VA has a lot of moonlighting attendings as well as residents from an academic teaching center, and they're not really familiar with it. And sometimes they don't want to order the labs because then they're responsible for reporting it back. And as we all know, the person that's injured cannot ask the exposed source to have blood drawn because that's considered coercion. We involved nursing and we involved the medical staff. So that medical staff put out a memo that the medical residents on call would be responsible for ordering source blood. And the nursing supervisor would be responsible for ensuring that the lab techs would go and grab the blood. So we did all of this in an order set that today, if you click on order set number 23 for an exposed employee, you have a choice for whether or not you're going to start HIV PEP or not. And there's a whole process that we have developed for that. And when you click on that, it'll automatically pop the labs you need, the CBC, the comp panel, the liver functions. And it'll automatically pop from pharmacy our routine HIV PEP dispension for a minimum of three day supply. So it covers the weekends for the ED. We then, after we did all of that, we then went and specifically targeted education for all the high risk areas. And we did a major collaboration between infection control and employee occ health so that areas that were really high risk were well aware of how they could mitigate some of their exposures. So as I said, we collect data forever. So we looked at the data from 2013 through June of 2017 because it took almost a year and a half for me to have most of this stuff implemented. And then we decided that we would separate out another benchmark because even though we set up with the order sets, it oftentimes takes a period of time for culture to change in an organization so that everyone can understand that this is an urgent matter and not just something poo-poo. We have a philosophy in our employee health department service, which is we protect the health of those that protect the health of veterans. And so it is our job to ensure that these things are done appropriately and in a timely fashion. And the other piece is that we looked at the comparison of the endpoints from 2017 to 2018. But I will tell you that I have data that I have continued to collect. And we have it straight out till 2021. So these are the results, which essentially, just looking at them, you can see the green are particularly encounter. Sorry, the orange are encounters. And you can see that that's pretty much remained stable. And then as we've implemented changes, the amount of HIV pep that's been dispensed has been decreasing. These are just the regular numbers so that you can have them as part of your data set. But essentially, the number of exposures have always stayed approximately somewhere around 45. But at one point, we were dispensing six out of 10 sticks were getting dispensed HIV pep and waiting an inordinate amount of time for their lab results. After we did the intervention, we noticed that there was a major decrease, even though the amount of encounters still remained in the 45, 47 range. But the amount of HIV pep that we dispensed decreased markedly. And these are our current trends where we're decreasing even more. And so what I can tell you is that from 2016 to 2018, the things that we're most proud of is that we decreased the time from results from greater than three hours. And in analyzing the data, we had to obviously get rid of some of our outliers. But we had outliers that were like three, or four, or five days. If any of you have worked in the VA, sometimes your source patient has left. Then you have to ask the source patient to come back and have their blood. And then it depends on whether or not they have another appointment that they're going to come back for. Almost, I would say, 99% of them never say no. They always come back. But they don't always come back in a timely fashion. So the other educational piece that we've given to all of the services is that the most important thing that you do if you have a needle stick is obtain that source blood. That's it. And all the attendings of all the services know that. And so we decreased it from over three hours, although I will say like five days, six days, and to 2.6 hours. And we decreased the average rate of HIV pep by almost 50%. We've continued to work on this. And I think now that the culture has been really established, I can honestly tell you that it is really, where in the past it was unusual for a surgeon to come after a stick to us, because it took too much time and they didn't get the results anyway, and whatever else. I can tell you almost to a beat that we have people that as soon as they get a stick, they drop what they're doing. And except if they're in the middle of the case, then as soon as their case is done, they're out and they come down to us. That we now average about an hour for HIV stat results. And that we continue to decrease the amount of HIV pep. This became a best practice for the VA, as well as a national model. And part of how Errolinda and I got together is because I revamped all of our paperwork for obtaining data for the bloodboard pathogen so that our paperwork matches exactly what the ED does. And that the ED now has a way of telling us that they had a needle stick. They have to co-sign us on the note. They have to leave a message on our cell phone, our phone, without patient information. We have a lot of regulations in the VA for patient confidentiality. Well thought out and really valid. But it sometimes makes it a little bit more difficult to get the process in place. But we're really, really proud of this. And we're really proud that we became one of the models for the VA to help decrease the amount of needles of HIV pep. As well as the educational models that we've put in place, and the paperwork that we've put in place, that's actually disseminated nationally. And now Linda will tell you hers. And I think if you need to leave, I know our session ends at 4 o'clock. But we'll make sure we'll have time for Q&A. OK, so my outcome pertains to, as a new provider as well for the VA, I was asked to be the alternate for the site accident investigation site subcommittee. And so as a newbie going into organization monthly meeting, like for most of us, we would just kind of watch the dynamics within the room. We make sure that we follow the agenda. And oftentimes, the pattern is that we spend most of our time talking about data, about injuries and illnesses that could be prevented. But we don't see what are we going to do differently with those data that we felt like they should be reduced or preventable injuries. So what happened then was, as a provider, wow, I see a lot of injuries related to bloodborne pattern exposures. My clinic, as well, I have the environmental registry exam. So for the veterans in the room, I applaud you. I thank you, you. That was the reason why I left Boeing to join the VA, to have the second part of my clinic to do the environment registry exam related to airborne hazard, Agent Orange, depleted uranium, and ionizing irradiation. So the last time I deal with bloodborne pattern exposures, I have more time to deal with my second clinic. So in terms of pattern, I'm seeing the same department getting, having exposures, your lab, your nursing, that would be your OR, your vascular surgery department for your podiatry, your dermatology interns starting the month of June to August. Certainly during the start of the influenza season, we're seeing a lot of influenza needle stick exposure. The mechanism of injury, same pattern. The lack of timely reporting. And yes, I do get a patient coming in at 3 o'clock in the afternoon on a Friday. And it's 120 degree out there, and they have not told their source patient. And so I have to be the bearer of that news to say, hey, do you mind coming back? And oftentimes, your vet will say, honey, it's 120 degree out there. I don't have a ride. I just got home. Or you have a vet that may say, gee, Orlinda, I just took the public transportation. I just left the clinic, and I just biked home. What do you say to that employee that just came to your clinic saying, what do you want to do now? So those are the things that I felt that those are learning moments for the employee. What we need to do differently moving forward. The average lost time away from the bedside is about two hours. And the average time for the supervisor to perform an in-depth safety investigation is about 45 minutes, taking approximately an hour of their time. So what we did then is that, obviously, we need to create a subcommittee looking specially on how we can reduce the bloodborne pattern exposures within my facility. We created a subcommittee that would include your line managers, your service line related to nursing, our top three, I call, infection control, risk management, safety. We involve our logistics department. They are responsible in procuring, dealing with our vendors. So we have a nurse that says, I have a better safety device out there. I need to make sure that I have direct contact with that logistics manager who can facilitate getting that safety device for end users to try out for the next 30 days. I was the lead. Knowing the dynamics within the VA as well, I've never in the military. My dad was in Philippine Navy. But it's a different dynamics within the VA, a lot of learning to do. So what I do is just kind of serve, see how the room, the personality plays out. But what I do recognize within the VA is that we need to get upper level management support that will hold me accountable as the chair of that committee and everyone who said, I volunteer. Does it make sense for you to volunteer for that committee if you're not going to do anything? So I had to meet with the director of the site, letting her know that these are the priorities of our facility to reduce bloodborne patient exposure. We had to come up with a purpose. What's the benefit for this committee? What are deliverables of our subcommittee? And how are we going to measure that we've accomplished x, y, and z? So we modified. I looked at the standard. We looked at the ECP. OH did not own the ECP plan, but I had buy-in from the infection control to modify the ECP. We had to retrain our supervisor on how to do in-depth accident investigation related to exposure. We developed and posted exposure process map and posted in areas that were considered to be high risk and collaborated with our logistics department. We revised the BPP injury packet. That's where I met Maria and say, what are the best practices within the VA? I had a section where we're asking for the name, the mechanism of injury, and a specific question. How can you reduce this injury or this event from occurring again? Because I want that injured employee to start reflecting back. What do I need to do? If it wasn't my fault because of the student helping with the suturing, how would I change the way I instruct that student to help me when we're in the OR? We've communicated with the ER as well. We had the same challenges as the Philly, where we have a lot of fellows or residents that are moonlighting in the ED. One of the big things, one of the big accomplishments was I benchmarked our local occupational health organization and say, hey, do you have any safety device and user evaluation form? And I used the CDC as well, but I developed three, one for safety syringe, IV catheters, and a phlebotomy and user evaluation form. And as you can see here, starting in 2016, this was the data that I could collect from my previous predecessor. We had 66 blood-borne progenic exposures that would include most of our exposures were needle stick injuries. Very few were body fluids flash. And oftentimes, what we'd do would be mainly in the eye due to lack of use of eye protection. And we've significantly reduced our exposures to 35. And that seems to be, in terms of some of the metrics that I've been reading, when comparing at Philly's metric, that seems to be plateauing. We have a 4,000 employee population, and that seems to be about the range of exposures. Can I reduce it even further? Absolutely. And so what we're doing now in our early morning huddle, we deal with steps. We spend 15 minutes within our immediate group. Steps, do we have a safety concern within your work group? Do we have enough team that would help us manage the workload within our facility to prioritize our work? And then E, what are the equipment issues that would prevent us from doing our job, and what are the process issues? So that gets elevated. If I am made aware of an individual that had a needle stick exposure because of improper or defective safety device, there is a situational awareness that gets elevated to a tier 2 level that says, by the way, be on the lookout. Or that if we're moving towards the use of going back from a generation 2 to a 3, we would then bring in our nursing educators to go ahead and help train the nursing staff on the use of the older generation because of a supply issue. So in terms of ongoing strategies, I think I spoke a little more on this already. We partner with the educators of specific lab and nursing. We include in our annual Nursing Skills Day for nurses to demonstrate how to properly activate safety devices. And the data shows you may have a safety device, but only 6% knows how to activate the device. They need to be able to demonstrate that they're competent in activating it properly. Retraining, obviously, our medical and surgical staff. I meet with the head of our surgery department to say, hey, you know your business more than I do. These are the patterns. What do we need to do differently to reduce injuries among our surgical staff? Cancer-related behavior, that often is hard to change. So what I tell the injured employee is that, remember, we've been trained to do, when we have to respond to do CPR, kind of be aware of your surrounding. So if you are going to be irrigating a catheter, be mindful what would be the potential exposure. And so be prepared for that. Wear safety glasses. On boarding new employees, I've alluded to this already early on, that there are a new set of eyes coming into the organization, they need to be engaged and involved. And certainly at injury reporting, we talked about escalation, investigation, and we also looked at monthly reporting with the stakeholders and the business service line leaders, because they own the problem. I'm there, we're there as a consultant, but ultimately, it is their department, they know their resources, they know their experts in that area, they know their job more than we do, so we're there as a consultant. Challenges and opportunities, Marie and I talked a lot about the changing staff members within the ED. We now have some stability within occupational health department, certainly the lack of use of safety devices that constantly you have to retrain, the lack of safety devices in the OR, we spoke again on that one at length. Again, if you have any ways of suggesting any simulation devices for suturing, that would be wonderful. The COVID-19 pandemic, it's a supply issue for everybody, the stress that had brought on to our staff. We saw a lot of uptick in November when the Delta and Omicron kicked in. I saw a lot of injuries, the influenza, the drive-through, we had one or two. I have a question to the group. I think we have five minutes. But what's the NIOSH recommendation for installing a fixed wall-mounted BBP container in a standing workstation? What's the recommended height? No, that's not the right answer. No, it's about 52 to 56 inches, slightly taller than me. And then how about if you're in a sit-down workstation? What's the minimum height? About 30 to 42. So if you're doing your environmental rounds, have someone in Philly, they do measurement. So you have to educate your EMS that are installing those safety BBP disposable containers that they have to be installed the way a NIOSH recommended. Let's see. With that said, I think that's the end of our presentation. Any thoughts, comments, and questions? I know we have five minutes left, but we'll be more than happy to answer any questions that you may have. We'll stay behind. And yes, the boxes are usually this high. And so that was one of our Philadelphia, as part of that process, we looked at all the boxes. And I had a pregnant female, rheumatology, who had to put her hand, was about Erlinda's height, and had her hand in the box and got stuck. And then I just was like, this has to be part of our environmental care rounds. And so now, every two weeks, when they do environmental care rounds, construction checks the height of needle stick boxes and EMS, or environmental services, checks to make sure that they are not overfilled, and that they have a, if they're below the mark or just below the mark, they have to check them out. And anything that has to do with needle sticks, as I'm sure Erlinda will attest to, or anything that has to do with blood-borne pathogen, I'm the point person in Philadelphia, Erlinda's the point person in Phoenix, meaning that if there's a new safety device that hasn't gone through logistics, if someone has had, some surgeon in the OR wants a more blood-resistant gown, if somebody needs to have training for EMS, it really is helpful to have one or two point people in your organization that are well-versed in this, and that have the authority to act, and to institute a stop, if you will. But also, they've got needles that don't have safety devices. Yeah, we have a lot of needles that don't have safety devices, and what we do is try to teach the, answer the question, as Erlinda did on her questionnaire, is what would you have done differently? And also, to remind people to be very mindful when you're giving injections, or doing an IND, if they're a surgeon doing an IND, or whatever, to be mindful of your surroundings, and if you're teaching residents as a teaching facility, to be aware of where your students or your residents' hands are, and dentists in particular, because patients move when things are in their mouth, and dentists are a particular challenge for us, because dentists have the highest risk of hepatitis B transmission of any of the occupational groups, primarily because HIV, hepatitis B is transmitted through saliva, and they also have the highest risk of mouth bites, which is then a bidirectional needle stick exposure. So we have done a lot of education with service chiefs and their departments on being mindful of your surroundings, that even though if you've done this a million and one times, take your time, think about it, remember what you're doing, remember your training, remember who's in the room. If you're done with your needles, clean up your mess. It's like, don't leave it on the chuck for somebody else. It goes in the needle stick box. That's why every room has a needle stick box. I have a question for you. So when we do all of our specimens, we need identifiers, rather than their names, and send the blood down. We have five hospitals in the system. Some of our hospitals are keeping the information from the bloodborne exposure in a separate paper file, separate from the EMR. Correct. Others are putting the blood results directly into the electronic database. They can put the employee, the exposed employee's results in the electronic database. They cannot put the source data into the database. And there are many organizations that keep either an Excel spreadsheet, if they need an electronic version of doing that. We keep a paper record. And we have, when we redesigned the paperwork, we designed an exposed employee packet, a clinician packet for doing shared decision making for HIV PEP dispension. And so we staple it. Really high tech here. We staple the pieces together. And then we put them together into the bloodborne pathogen book. But they can always be separated. And I personally, myself and one other RN, keeps the spreadsheet for when things have happened. And that's in a shared drive that can be accessed, but only by people in AHRQ Health. Yes. Actually, in the VA, they have a right to the information. In the VA, they have a right to their privacy. So we don't pursue them. If they don't want to have the vaccine, we don't go for that. But we always ensure that they know what the risks are and whether or not, if they want to change their mind. Because sometimes when they're a new employee, I knew I was electrifying, but when you're a new employee, you don't really know what you're going to be doing. Right? We know as nurses what we're going to be doing. We know as physicians what we're going to be doing. But at EMS, you don't really know. You don't really know what department you're going to be looking in. So we always make sure that they recognize that they're always welcomed. Our door is always open to come back and discuss any employee health topic that they need to have discussed, including hepatitis B. Okay. They declined. We do. We do. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. We do do that. And in fact, if they do decline, we also ask them gently the reasons. Like, they want to give us the reasons for why they might decline. Some people are afraid of needles. And so we have brought out our little needles and said, look, it's not that bad. Don't worry about it. I'm really good at this. But, you know, you come back when you're comfortable. Do you want to bring somebody in with you to hold your hand while you're doing it? Some people are afraid of vaccines, and some people have some misinformation about vaccines. So there's a whole different topic on what we do for vaccine education. But we try really hard to dispel any myths that they may have. But for us, if they decline the vaccine, they decline the vaccine. They have a right to decline. So we do our due diligence in that we make sure that they understand what they are declining. They understand the lack of protection that they would have for hepatitis B and why that's important. And now, given that the CDC has recommended universal vaccines for hepatitis B for everyone up to the age of 59, that we kind of make sure that they are aware that if they were born today, you would have had it at birth. So we try to make it a really interactive conversation. Isn't that right, Linda? So then you're dealing also with patients that might have the hepatitis B from exposure as well, either chronic carriers or have passed transplant centrally. And they have no records available. And will you do titers on them if they would agree to them? So I would like to respond. So I had an ED. We do pre-placement exam. We're probably one of the few organizations that still do pre-placement exam. It's being reviewed. And so one of the discussions that we have is that when that applicant comes into our office, that they bring a copy of their immunization titers. I've learned from my past experience is that having someone bringing a record that they're positive for hepatitis B, I need to have the lab value. What I've learned is that the nurse who probably entered that into STIX database misread the lab report, that it was indeterminate, and entered it as positive. So I learned now to go ahead and offer. It's no cost if they wish to have their titers drawn for hepatitis B surface antibody. And I, for case in point, with an ER doc, I tell him, I said, you're going to be working in the ER, which is a high-risk area. I highly recommend. Certainly, this is strongly recommended for you to get hepatitis B vaccination. So that certainly is an option. Having that provider-applicant relationship would certainly help them educate. Right. In Philadelphia, if we don't have three documented doses of hepatitis B vaccine or now at Heplisav-B two doses of documented hepatitis B vaccine plus a positive titer drawn four to six weeks post, having a third dose, that is not an acceptable rate of immunization for health care providers for hepatitis B. So we will almost everybody gets drawn a hepatitis B titer unless I have three documented doses plus a titer. And I know that there's been some controversy with that because most of us have been in health care. I mean, I received the first blood-borne made hepatitis B vaccine back in the 80s. So, yeah, right? Okay. So we're all from pooled blood products of people that were hepatitis B positive. But in any event, regardless of that, if you don't have a copy of my documentation that I received three documented doses and have a positive titer, you are not immune. And the reason why is hepatitis B is a really good vaccine. It works really well. The third dose is you don't have that third dose. So many people say, oh, I have two doses and I'm positive. The third dose is really what gives you long-term immunity for at least 30 years. So without that third dose, I cannot, as a clinician, guarantee to my employee that you will have long-term protection from this virus. And I get sometimes very graphic with some people and sometimes in a lower level, but to basically say, you know, you could get cirrhosis. If, God forbid, you had a needle stick and, God forbid, the person was hepatitis B positive and shedding, you're at a very high risk if you're not protected of contracting that hepatitis B. So we make a real concerted effort for education. And I think that's something that AHRQ's role really needs to be in that educational realm. But I can sympathize with you. Internationally, my parents are immigrants or were immigrants. And I doubt any of my cousins in their country have been immunized for whatever. Yes? How do you get the E.D. buy-in to test both the source and exposed patients? Are the E.D.s legally exempt? So they don't. The E.D. does not. What they are required to do is to contact the medical resident on call. And the medical resident on call is responsible for getting the source blood. The exposed patient, the E.D. will get it. But they will not get the source. And nor should they. Because we have to be able to get verbal consent from the source patient. We don't have to document it written, but you need to at least give verbal consent that I'm agreeing to be tested for these. The electronic medical record on the source patient, they will have blood work done. But what it will say is blood obtained as source of a needle stick. And the employee record, like when I go into a veteran's record, because you technically can't go into a veteran's record, if they are a source blood and I go into their electronic record, and for those of you that don't know, the VA was the first people to have the electronic record. It's archaic, but it works. When I go into that veteran's record, I will type an e-health note that says entered record to obtain source result. That's it. Done. And so to answer your question, too, regarding the E.D., because E.D. is your backup, so you need to be able to establish protocol with them, work with the attending to say if they're going to be seeing part of that care provided should be obtaining baseline testing for that source or exposed employee. So here's what you can do. If you design the paperwork, this is what I did. If you design the paperwork, and then I hand brought it to the E.D., and then I met with the chief of the E.D., and then I met with some of the clinician staff. And I said, whenever you have a needle stick, this is what I need you to fill out. Just fill it out, put it in a manila envelope, and I will come get it. And so that's our process, and we do that in our satellite clinics, except now they'll call me. But that's a process that you might be able to establish, and 22 sites, you might have some sort of electronic way of notifying you. Right. It's really hard, and I'm not going to say it was not an easy project to do, but I think it's a well-worth project. And I think it's the amount of exposures and the amount that you see, it's really very low numbers, low denominator numbers, but it's a high impact, particularly on the exposed employee who has family, is married, or has a partner, has children, and they think about all these things when they're in your office, basically shaking because they just had a needle stick. On top of, I didn't engage the safety, and now my supervisor knows about that. So it's a big process for that. So I think it's really important to try to standardize that task, not the clinical judgment piece. I would never standardize clinical judgment piece. I think that's really the perviance of the clinician that's doing the treating. But I would standardize the process, and I would standardize the tasks associated with it. And luckily in the VA, because pharmacy makes our, you know, we can't choose anything we want. So for HIV PEP, it's really Truvada and Rotavir. And then we have to consult ID because obviously if the source is HIV positive, we need to make sure that the meds that the source is on are, that wherever we put the exposed employee on will cover the amount that they may miss from what the source is on. Oh, there's a question. Can you, they repeat the questions from the audience. Shoot. Sorry about that. So the question was? The question was, how do you get ED buy-in? At 22 satellite locations. Sorry about that, Alyssa. But thank you all, and really thank you for allowing us to present. Thank you. Thank you.

needle stick injuries

HIV post-exposure prophylaxis

bloodborne pathogen exposure

healthcare settings

bloodborne pathogen exposure control plan

high-risk areas

nurses

operating room

process improvement

collaboration

workplace safety