Report from the SFDPH
SFDPH's Safe Device Committee: A participatory approach to injury prevention

Rajiv Bhatia

The Centers for Disease Control and Prevention estimate that 384,000 percutaneous injuries occur among hospital employees annually. These exposures to blood or body fluids create significant risks for healthcare workers for contracting HIV, hepatitis B and hepatitis C. The San Francisco Department of Public Health (SFDPH) serves a population with a high prevalence of infection with HIV, HBV, and HC. In 2002, SFDPH employees reported 92 exposures involving contact with blood through a puncture or a cut. Several health care workers at San Francisco General Hospital (SFGH) and related clinical sites have acquired human immunodeficiency virus (HIV) as a result of work-related exposures.

California law requires that health care institutions take steps to prevent occupational injuries to blood-borne pathogens. Recent revisions to California labor law require institutions to provide employees devices with engineered injury protection when available. Engineered protection refers to devices such as a syringe that is sheathed as the health care worker withdraws the needle. The U.S. General Accounting Office estimates that 69,000 needle stick exposures could be prevented by the use of needles with safety features.

Though our department began to use safety devices well in advance of regulatory requirements, the lack of device standards and official guidance for device selection and evaluation limited our confidence in the safety and efficacy of new devices. Another shortcoming of device selection efforts was the limited involvement in the device selection process of frontline health care workers. Frontline workers have firsthand understanding of how working conditions and work environments influence the risk of injuries. Specifically, they understand how factors such as clinical procedures, patient characteristics, medical equipment, and hospital design influence the choice of what device will work best for a particular institution.

In 1999, catalyzed by the need for an effective process for device selection and by disagreement among staff and management on the best approach, the administration of SFDPH along with representatives from labor agreed to convene the Blood-Borne Pathogen Safety Device Committee (SDC). The administration invested in this joint labor-management committee the responsibility of monitoring injuries and their risk factors, selecting the best available technology for reducing injuries, and making recommendations to ensure adequate user training and safe work practices.

With few precedents, committee members, representing equally both labor and management, had the task of developing a novel device selection and implementation process. Early in this endeavor, the committee recognized the need to balance device selection with attention to the work environment and to training needs, and the need for skills and capacity-building among its own members. The SDC identified five general areas of work activities: communication, risk assessment, work and clinical practices, training, and safety device selection and evaluation. The committees also benefited from the pioneering work on device evaluation developed by the project Training for the Development of Innovative Control Technologies (TDICT).

The SDC has had a productive four years. It revised the department's injury surveillance instruments, promoted injury reporting and tracked injury data in order to identify practices and settings responsible for the greatest number of injuries. Committee members researched best practices in device selection and developed institution- and device-specific evaluation protocols. They evaluated new engineered devices including needleless IV tubing, safety syringes, scalpels, and devices for the insertion of IV catheters. The committee helped the department's management coordinate the purchasing and distribution of new devices and the training needed for changes in work practices. More recently, it has made recommendations for safety procedures for smallpox vaccination and created a digital photo library of safe devices.

Because we have only recently implemented many of the new devices and work practices, we do not yet have data on the impacts of this process. As the work continues, a high priority of the committee will be closely examining injury data to evaluate the successes and shortcomings of its efforts. Nevertheless, the committee is steadily approaching its overall aim to create a sustainable process to screen, pilot, select, and monitor emerging technologies for workplace blood-borne pathogen exposure.

Critical to the success and sustainability of this committee has been paid time for committee member activities, a dedicated part-time occupational safety and health position for committee activity coordination, and accountability of administration to the committee's recommendations. From our administration's perspective, the devolution of decision making authority to the SDC has been a wise investment. According to Mary Magee, the first labor co-chair of the committee who is a staff nurse and member of SEIU Local 790, "the joint labor- management development of the SDC has created both mutual trust and shared expertise. Frontline staff sees a willing commitment on the part of the administration to worker safety, and administration sees that frontline participation can improve decisions and advance a complex process of the changing unsafe work practices."

Overall, this participatory effort not only enables our organization to meet its regulatory responsibility but also achieves the aims of worker protection in a way that integrates the complex needs of our diverse institution and gains the acceptance of staff and administration. In the future, we hope that such team approaches find applications in other important challenges for worker health and safety.

Rajiv Bhatia is the director of Occupational and Environmental Health and assistant clinical professor of medicine at the University of California, San Francisco.