Hidden dangers

Laundry
staff in hospitals may be at risk from blood-borne viruses from contaminated
instruments. However, there are measures you can take to keep safe, by Eileen
Smith

Inoculation through the skin with a contaminated sharp instrument is the principle
risk of transmission of blood-borne viruses to healthcare workers (PHLS 2000).1

Numerous studies have shown that such injuries occur in a variety of
settings and are frequently associated with the inappropriate handling and
disposal of sharps (Wilson 2001).2

A recent survey by Godfrey (2001) indicated that two out of five injured
people were not the original users of the sharp.3 Downstream injuries are
common, and May and Brewer (2001) corroborate this evidence.4

Staff at risk

The laundry staff employed in a particular NHS Trust hospital were in danger
of contamination by a blood-borne virus by coming into contact with items such
as:

– Dirty theatre instruments

– Used hypodermic needles

– IV cannulae

– Blades

– Sharp teeth

– Splinters of bone

Any of these items could have been accidentally or negligently dropped among
the linen. These ‘sharps’ may cause a percutaneous injury, which is a very
distressing experience for the employee, often compounded by an inability to
identify the donor/source, to facilitate a risk assessment for blood-borne
viruses.

Despite the availability of vaccination against Hepatitis B, there is still
a risk to employees. According to a report from the RCN in 2001, evidence from
the US suggests that the probability of a healthcare worker becoming infected
by a contaminated sharp is:

– one in three for Hepatitis B,

– one in 30 for Hepatitis C

– one in 300 for HIV5

Local measures in place

Further investigation at the hospital revealed that a variety of measures to
reduce the risk of sharps injury had been put into place by the Trust and the
Health and Safety Group, such as protective clothing for laundry staff (as
recommended in the Health Service Guidelines HSG(95)18),6 repeated educational
forums for nurses, doctors and allied healthcare workers, stringent checks of
theatre instruments and a ‘name and shame’ policy. A specific project group was
formed to look at the laundry problem.

The primary focus of evaluation of the injury prevention strategies was to
improve the effectiveness of the interventions as described by Feyer and
Williamson (1998).7

However, it was realised that the success of the measures, when put into
place, depended upon compliance by staff. An examination of the job/task factors
also revealed that safe working practices interfered with the speed of
performance and this was the most reported reason for non-compliance
(Hoffman-Terry et al 1992).8

So, despite the attempts of the Trust to develop safe systems of work for
employees, some sharp items still appear in the laundry.

Legislation

Employers have a responsibility to protect employees from such occupational
health risks under the Health and Safety at Work Act (1974, ss. 2 and 3).9
However, they have a more specific duty to prevent exposure to biological
agents under the Control of Substances Hazardous to Health Regulations (COSHH
1999)10, (Ballard 2000)11.

These regulations, which incorporate the Approved Code of Practice on the
control of biological agents, would seem to be the most relevant legislation in
the UK relating to sharp injuries, including blood-borne viruses.

In the Control of Substances Hazardous to Health Regulations 1999 (COSHH
1999), regulation 6 requires that an employee is not exposed to any substance
hazardous to health unless there has been a suitable risk assessment made and
steps taken as a result of the risk assessment to protect the employee, which
meet the requirements of the regulations. With regard to blood-borne viruses,
employers are advised to assess:

– Which virus may be present

– What effects it may have

– Where the virus is likely to be present

– Ways in which employees may be exposed

The chance of exposure, frequency of contact, the protective measures used in
the work, where information is available, whether or not the blood or body
fluids come from an infected individual (Ballard 2000).

In addition to this, The Management of Health and Safety at Work Regulations
(HSE 1999) provide for risk assessment, effective planning, organisation,
control, monitoring and review of the preventive and protective measures.
Employers must also provide employees with health and safety training.12

Unfortunately, the risk, although somewhat reduced by the above strategies,
still remains, and the cost both to the employee (physical and mental) and
employer – including the financial costs of an injury, treatment and possible
legal processes (RCN 2001)5 – are too great to ignore.

Viewed together, these conclusions highlight the need for complementary
measures to be found. In the report, The influence of employee/job task and
organisational factors on adherence to universal precautions among nurses,
which appears in the International Journal of Industrial Ergonomics, it says it
is possible to use available engineering technology to reduce direct exposure
to harm in certain circumstances.13

Mechanical measures

The project group reached the general consensus that mechanical/engineering
measures might be the answer to creating a safer working environment at the
Trust. However, so far, technology has not been successfully applied to the
problem in this country – even in the US, where legislative costs are high, a
solution has not been found either.

There are an estimated 10 million healthcare workers in the US experiencing
between 600,000 and 800,000 needle-stick injuries per year (GAO 2000).14 In an
attempt to reduce this number, new legislation will mandate the use of safer
devices (Needlestick Safety and Prevention Act 2000)15, but this solution may
not be a catchall.

A local initiative was developed at the hospital to find other ways of
preventing needle-stick injuries in the laundry. This included a visit to a
local airport, where an offer had been made to test the ability of their x-ray
scanning equipment to pick up small sharp items such as hypodermic needles,
concealed in the laundry, with a view to obtaining similar equipment for the
hospital. Disappointingly, the test was not successful, however, it did provide
the impetus to explore further means of detecting sharps in the laundry.

The methods used by other establishments to monitor for sharps were also
investigated, but networking with other hospital laundries in the country
proved that the problem was widespread and solutions to date were inadequate.
However, contact with a local prison revealed that a hand-held metal detector
served their purpose. The manufacturer of this machine facilitated the loan of
a superior hand-held machine to trial. Unfortunately, this was not successful
either as it involved increased handling of the linen.

Discussion with a colleague revealed that food manufacturers use metal
detection to screen pre-packed food before it leaves the factory. A local
producer explained that a machine incorporating a metal detector housed in an
arch above a conveyor belt on which cartons of food passed along, is used as a
quality-control method. This company kindly provided a list of manufacturers of
similar machines used by various industries.

A telephone trawl of a selection of those manufacturers revealed that the
majority believed the task of detecting tiny metal items concealed in laundry
was, to date, insurmountable.

The aperture under the detector needs to be relatively small to afford
greater sensitivity – even more so to detect tiny items such as suture needles
– so they did not anticipate being able to build a machine of the proportion
required to screen dirty laundry.

However, one company, Cintex, which manufactures needle search metal
detectors for clothing and footwear industries, expressed an interest in the
dilemma.

The combined objective was to determine a method of inspecting the laundry
for metal contaminants and, in particular, sharp instruments, to eliminate them
from the laundry chain before they caused harm. Cintex responded to this
problem by involving its research and development specialists in a project to
find potential solutions.

Numerous visits by the company representative resulted in an attempt to
modify one of the existing needle search machines – a metal detector sited
around a conveyor belt. A problem lay in the size of the aperture required to
pass the laundry under the detector. However, using new advancements in its
electronics and software, Cintex manufactured a larger aperture detector, while
still maintaining excellent sensitivity.

This machine was installed into the laundry for a trial period and proved
successful in monitoring dirty linen. It was subsequently purchased, which
resulted in a reduction in the number of staff required to handle the dirty
laundry.

Two workers have been trained to use the machine and have been provided with
protective gloves for placing linen on the conveyor and removing suspect items
identified by the machine. Their knowledge of the dangers of blood-borne
viruses was updated, their Hepatitis B status checked and the procedure
following a needle-stick injury was re-enforced.

Research is ongoing to extend the machine’s use to wet laundry, which would
provide more comprehensive monitoring.

Conclusion

Following the installation of the machine, other uses are coming to light,
such as screening newly-stitched theatre swabs for needle remnants. There is
still a long way to go to perfect the system in the laundry, but this machine
provides a broader, more multi-faceted intervention strategy that does not rely
so heavily on the individual worker’s behaviour and ability to follow safe
practices in all situations. Instead, the new equipment complements education,
active prompts and reminders. At the very least, it is a step in the right
direction to fulfil the Trust’s responsibilities in protecting employees from
harm.

Eileen Smith RGN, BSc (Hon’s) Health Studies, BSc (Hon’s) Community
Nursing/Occupational Health, C&G FETC 7307, ENB 998, is a specialist practitioner,
OH department, Sunderland Royal Hospital

References

1. Public Health Laboratory Service (1993), Unlinked anonymous monitoring of
HIV prevalence in England and Wales: 1990-92, CDR Review, 3(1): R1-11

2. Wilson, J (2001), Safe Sharps Management in the Health Care Environment,
Cory Bros, London

3. Godfrey, K (2001), Sharp Practice, Nursing Times, 97 (2): 22-24

4. May, D, Brewer, S (2001), Sharps injury: prevention and management,
Nursing Standard, 15 (32): 45-52

5. Royal College of Nursing (2001), Be sharp – be safe, avoiding the risks
of sharps injury, RCN London

6. Health Service Guidelines (1995), Hospital Laundry Arrangements for Used
and Infected Linen, NHS Executive, Crown

7. Feyer, AM and Williamson, A, (1998), Occupational Injury, Risk Prevention
and Intervention, Taylor and Francis, London

8. Hoffman, Terry M, Rhodes, LV and Reed, JF (1992), Impact of human
immunodeficiency virus on medical and surgical residents, Archives of Internal
Medicine, 152, 1788-1796

9. Health and Safety at Work Act (1974)

10. Health and Safety Commission (1999), General COSHH AcoP (Control of
Substances Hazardous to Health), Carcinogens Acop (Control of biological
agents), Control of Substances Hazardous to Health Regulations 1999, HSE Books,
Suffolk

11. Ballard, J (2000), HIV and viral hepatitis at work. An introduction to
the relevant health and safety law, Occupational Health Review, May/June 27-32

12. Health and Safety Executive (1999), Management of Health and Safety at
Work Regulations, London, The Stationery Office

13. DeJoy, DM, Murphy, LR and Gershon, RM (1995), The influence of
employee/job task and organisational factors on adherence to universal
precautions among nurses, International Journal of Industrial Ergonomics, 16,
43-55

14. General Accounting Office (2000), Occupational Safety: selected cost and
benefit implications of needle-stick prevention devices for hospitals,
GAO-01-6R, United States General Accounting Office, Washington DC 20548

15. Needle-stick safety and prevention Act section (2000), 2 (7), US Senate

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