Clinician survey on glass safety

by Ron Stoker

My father-in-law recently succumbed to a sepsis infection. He languished in the intensive care unit for about a month before he passed away. I was grateful for the men and women who took care of him during that time period. I had many discussions with them about the products that they were using. During the time that Dad spent in the hospital I had the opportunity to review a variety of safety products. (It gave us something to do instead of just focusing on our own problems!)

           I decided to look at all of the conventional medical products that were being used instead of safety products, and particularly noticed that glass was still being used in many instances. I decided to conduct a survey of healthcare workers to see how widespread the use of glass is in the hospital laboratory. I sent out an invitation to healthcare workers to participate. There were 277 respondents to my survey. I promised the participants in my survey that I would not identify individuals or hospitals so I will be quoting clinicians anonymously, but I do have the survey information in my personal files.

Over the last 10 years I have promoted the use of safety products to eliminate accidental needlestick injuries and bloodborne pathogen exposures. This has included the encouragement to use plastic products instead of glass products. I was surprised to find that many healthcare workers are still using glass products even though plastic ones are available. This has resulted in many injuries and bloodborne pathogen exposures from broken glass.

“Labs just really started to use plastic, and I’ve been a tech for 37 years,” said one respondent. “NOTHING was plastic back then, and I cut myself quite a few times. The biggest problem was glass tubes, and glass blood culture bottles, not to mention glass slides! It’s very easy to become a ‘blood brother’ with a patient, when the tube you just drew on him crumbles in your hand!”

Another respondent indicated:

“We have decreased our sharps injuries by 58 percent over the past four years by eliminating any glass or ‘sharp’ device which is available in a safer product. Only lab products now in use that are glass are the yellow top tubes that can be used for blood culture draw, glass body fluid vacuum bottles, and glass QC serums. We would like to get these in a safer product. We have had no injuries with these, but (the) potential is there.”

Some institutions have categorically refused to use glass in any form.

We do not use glass capillary tubes, vaccutainers, or body fluid collection devices.

 The next section of this article will highlight specific questions asked during the survey, the survey results, comments from participants and general comments.

Have you or any of your staff experienced glass breakage from glass capillary tubes?

            Yes 31.2%

            No  68.8%

Although plastic capillary tubes are available, glass capillary tubes are still being used for the collection of blood in a variety of healthcare settings. The challenge comes when these fragile glass tubes break when inserted into putty to be sealed or centrifuged. The breakage of the capillary tube when filled with blood can result in a penetrating wound and blood inoculation to the user. An injury from a glass capillary tube resulted in the transmission of human immunodeficiency virus (HIV) to a physician who died of acquired immunodeficiency syndrome (AIDS).¹ When glass capillary tubes break they can cause blood to splatter exposing clinicians to bloodborne pathogens. Mylar coated capillary tubes can help contain broken glass but plastic capillary tubes remove the risk.

When the capillary tubes are placed into a centrifuge and break, clinicians are exposed to micro droplets that could potentially contain viruses and other pathogens if inhaled or splattered onto skin. This is in addition to the contaminated glass shards that can embed into skin. Bottom line—get rid of glass capillary tubes.

“We have switched to reinforced plastic capillary tubes because of the risk. Rarely have injuries related to broken glass now that capillary tubes are available in plastic.”

“Most of our products are no longer made of glass, including capillary tubes.”

Have you or any of your staff been injured by glass body fluid collection devices?

            Yes 12.8%

            No  87.2%

I was surprised to find almost 13 percent of the respondents had staff member injuries from glass body fluid collection devices. There are many plastic versions available.

Have you or any of your staff been injured with broken glass evacuated tubes?

            Yes 12.4%

            No  87.6%

I was pleased to see that this number was just a little more than 12 percent. Just 10 years ago there were hundreds of stories of individuals who had been injured by broken glass evacuated tubes. Several clinicians have shared stories with me about removing stoppers off of blood tubes and cutting their hands on broken glass.

“We have had broken glass but no injuries to speak of, but I did once find a broken vacutainer in a clean lab coat back from the laundry. Luckily I was not cut.”

“We are fortunate not to have many injuries here and have removed most glass vacutainers from our testing process.”

“We have 99 percent usage of plastic vacutainer tubes.<$>”

“We no longer use glass cap tubes.”

Dr. Janine Jagger has indicated, “Plastic substitution, especially for blood collection tubes and capillary tubes, got off to a slow start but is picking up steam. Each product category requires a focused initiative. Initial industry efforts were directed toward needles. But the focus on glass has recently increased. The Joint Safety Advisory on the risks of glass capillary tubes issued by the FDA, NIOSH, CDC and OSHA in February 1999 provided tremendous momentum in the transition away from glass capillary tubes. Glass is on the way out but everyone including manufacturers, purchasers and users need to push to complete this transition as quickly as possible.” ²

Have you or any of your staff experienced injuries from glass vials?

            Yes 22.5%

            No  77.5%

This number is higher than I expected. Glass vials are not ampoules which will be discussed later in this article. Many medications come in glass vials. The top of a vial is accessed by removing an aluminum top and then pierced with a needle. Broken glass vials would indicate that they have been dropped or banged against another hard surface.

Have you or your staff been injured from QC serums for chemistry analyzers that come in glass?

            Yes  5.9%

            No 94.1%

I was not surprised to see this number at this level but we should encourage manufacturers to come up with a plastic version.

Have you or any of your staff experienced injuries from broken glass ampoules?

            Yes 30.5%

            No  69.5%

Ampoules are small glass vessels in which liquids for injections are hermetically sealed. When the cap is snapped off, glass chips can fly off and a jagged or sharp edge can cut the hands of clinicians and others. The scoring at the neck does not always break where it is intended. This is due to the glass re-melding to some degree at the score line. In one study more than 62 percent of nurses said that they have been cut by a broken glass ampoule. Safety ampoule breakers prevent this problem by covering the glass ampoule during the breaking process, thus protecting the clinician’s hands.

“It is extremely easy to get hurt when snapping off the top of an ampoule—even when using a padding of some kind around the top.”

“API Survey blood gas ampoule breakage caused exposure through glove.”

“Glass ampoules always cut people even with cracker tops.”

“Have been injured myself opening ampoules of meds.”

“I was injured by a broken glass ampoule with bone cement.”

“Ampoule broke in one of my tech’s hands as she was snapping it open (these vials are scored) causing a minor cut on one of her fingers.”

There are a variety of ampoule breakers that are commercially available. These include the Snapit Ampoule Breaker from Qlicksmart and the Disposable Ampoule Breaker from Starr Systems. They can help to remove the danger from opening glass ampoules.

Have you or any of your staff experienced injury due to broken glass thermometers or broken glass blood pressure apparatus?

Yes   6.9%

No  93.1%

“I broke a glass thermometer that had mercury in it. We have since removed all thermometers like this from the facility.”

Have you or any of your staff experienced injuries from glass breakage of microscope slides or microscope cover slips?

Yes 27.8%

No  72.2%

“While removing a coverslip, it shattered and the employee suffered numerous small cuts and embedded shards of glass in their hands.”

“One of my staff was injured by a glass coverslip while performing ANA IFA. It cracked while she was applying the coverslip to the slide. A piece of it went into her finger. She removed the piece with tweezers and went to occupational health for treatment. She returned to work within the hour.”

“Had a microbiologist dry a glass slide by blotting the slide with a paper towel then broke the slide and cut herself.”

Unfortunately, I do not see plastic cover slips and slides for microbiology in the near future. Are you aware of any developments in this area? Please contact the author with any product developments.

Have you or anyone else on your staff ever experienced blood culture bottle breakage?

Yes 55.8%

No  44.2%

Okay, this one had the highest number of glass breakage and injuries of any category in the hospital laboratory. Here are some of the comments.

“We have foam cushioning in our pneumatic tubes to avoid breakage.

“I do not care for the shape of the bottleneck blood culture bottle of the glass system that we have. It has a real vulnerable neck that is subject to breakage. The techs usually grab and carry them by the neck which I feel can be easily dropped and broken. I have had one drop and you did not see the crack immediately. Dropping a bottle really can be dangerous for the employee, subjecting them to unnecessary blood exposure. Outreach clients need to transport these by our courier system carriers. That is another area of concern for breakage in the courier vans.”

“We use plastic now, but I know our biggest problem was that the hospital patient labels with the collection label, the bottle was very tight in the instrument and when trying to remove it, they would occasionally break. This was a huge mess, with the decontamination time and cleanup involved. Now we only use the plastic bottles and have had no breakage problems.”

“When we used glass bottles more than 3 years ago, we experienced occasional breakage when bottles got dropped on the floor. No injuries were associated with these breakages.”

“Most injuries occur from broken glass during shipment and then having injury due to the shards when removing the product from the packing box.”

“I recently dropped a glass blood culture vial from no more than 2 feet to linoleum and it shattered. I was very surprised! We’re happy that we have plastic bottles now!”

“Many years ago I had a blood culture bottle snap off at the neck while still in the instrument, pouring the contents down the front of me. While not a sharps injury, it was still an exposure.”

“Any injuries from broken glass blood culture bottles involve tech time to go to health service for blood testing for hepatitis, HIV, etc. Long wait in health service. Loss of tech time, money for testing, and anxiety from tech for exposure.”

“I am the laboratory safety officer so I keep track of all laboratory injuries. The one injury I can remember was when a phlebotomist went upstairs to draw a patient blood culture. He had no space on his tray and placed the glass blood culture bottle on the patient’s bed. The patient moved his arm to scratch his nose, and in doing so, the blood bottle rolled off the bed and onto the floor, and broke and plattered all over the floor. The lab assistant got splattered in the face and eyes.”

On average, how many instances of bottle breakage do you think occur in your hospital in a year?

1-5:      73.3%

6-10:    14.3%

11-15:    3.5%

16-20:    2.7%

>20:         .2%

Do you use a pneumatic tube system for bottle transport?

Yes 53.6%

No  46.4%

Have you or anyone else on your staff experienced bottle breakage in the pneumatic tube system?

Yes 27.8%

No  72.2%

On average, how many instances of bottle breakage do you think occur in the pneumatic tube system of your hospital each year?

1-5:      88.3%

6-10:      5.1%

11-15:    1.9%

16-20:    1.9%

>20:       2.8%

Have you or anyone on your staff experienced bottle breakage inserting or removing bottles from your blood culture instruments?

Yes 25.9%

No  74.1%

On average, how many instances of bottle breakage do you think occur in your blood culture instrument each year?

1-5:      94.1%

6-10:      3.6%

11-15:    0.9%

16-20:    0.5%

>20:       0.9%

Do you discard your blood culture bottles in standard or sharps containers?

Standard Containers:                32.6%  

Sharps Disposal Containers:      67.4%

“Our broken BC bottles usually happen with couriers bringing them to this site and it is already broken from the bumping around it gets in the cars.”

 “A coworker removed a glass blood culture bottle that crumbled in her hands. It had essentially been held together by all of the labels that were put on the bottle. It could have been much worse. Now we utilize face shields to remove bottles just in case. We also incorporated in our procedure for the bottles to be fully examined before they go into the instrumentation.”

“Bottle broke in instrument, tech cut her hand removing bottle.”

“Since plastic can be easily substituted for glass in most all cases, we expect employers to use plastic where appropriate …”

Which type of blood culture bottle do you consider “green?” (glass or plastic)

Glass    51.1%

Plastic  48.9%

Now, this one was a real struggle for me. Our family makes a real effort to be as green as possible. We recycle whenever we can. However, in this instance, I have to admit that although the majority of respondents indicate that they consider glass blood culture bottles to be green—this is not a green issue. It is a safety issue!

“It isn’t just a green issue it is safety, that is why everyone is using plastic and we won’t switch; people are too rushed and drops happen”

This is where I believe that many facilities have made some poor choices—considering the use of glass to be the “green” thing to do while ignoring the safety aspect. I believe there are many reasons to make a switch to plastic including:

• Employee safety—It is important for your employees to recognize that their health is as important to your facility as the bottom line. Plastic products are less likely to break, reducing the risks of exposures to bloodborne pathogens.
• It’s the law!—OSHA has mandated that glass be replaced with plastic and that “engineering and work practice controls should be used whenever possible to minimize employee exposure.” Changing from glass to plastic products will bring your institution into compliance with the law, which will reduce fines and citations.
• Cost of waste disposal—Plastic products typically are lighter than glass counterparts making disposal of them more economical.

In my conversations with clinicians it would appear that many have converted from glass blood culture bottles to plastic ones. As I talked with those that had made the switch I asked why they made the switch.

Safety was the biggest reason but not the only one. Many have switched because the plastic bottles are lighter than the glass counterparts. This made disposal less expensive. They felt that the cost to covert to plastic created an overall savings. And that is just the hard cost.

The treatment of accidental sharps injuries from broken glass blood culture bottles runs from $2,500 to $9,000 depending on which part of the country in which I have talked. This would include not only time spent in testing but lost work time, followup care, etc. These costs are minimal, however, when compared to the costs associated with a clinician exposed to contaminated blood that seroconverts to hepatitis or HIV.

In addition, OSHA continues to cite facilities that are not in compliance with the OSHA Bloodborne Pathogen Standard. The standard indicates that if safer medical devices are available that reduce the risk of injury to employees, they must be substituted for conventional glass products. The intent of the Standard is that engineering and work practice controls should be implemented to eliminate or minimize exposure to bloodborne pathogens.

The Compliance Directive, used by OSHA inspectors, indicates that citations should be issued “if no engineering controls are being used to eliminate or minimize exposure … If a  combination of engineering and work practice controls used by the employer does not eliminate or minimize exposure, the employer shall be cited for failing to use engineering and work practice controls.”

I thank the many clinicians who worked with my father-in-law during his last fight. We were so appreciative of their efforts in his behalf. I am also appreciative of those who participated in the survey. It helped to open my eyes to some of the challenges facing healthcare workers.

References

1. Aoun, H.: When a house officer gets AIDS. N Eng J Med 321(10):693-696, 1989.  
2. Medical Laboratory Observer, May 2001.

Ron Stoker, MS, is the executive director of the International Sharps Injury Prevention Society (ISIPS). He has 29 years experience in the medical device industry as a researcher, marketer, educator, consultant and healthcare worker advocate. He has written more than 200 medical journal articles, primarily on sharps injury prevention, infection control, and hand hygiene. Mr. Stoker has his BS in Pre-Medical Zoology from Brigham Young University, an MS in Bioengineering from the University of Utah and an “honorary doctorate” from the school of hard-knocks. As a result of a surgical mishap he was rendered a quadriplegic in December 2006. Informed that he would never walk again, with tenacity and a “supportive and mean wife,” Mr. Stoker taught himself how to walk again. He says that he walks like an “alcoholic” but is really just a recovering quadriplegic!

Mr. Stoker has conducted workshops and Congresses on sharps safety at national and international meetings for the last 10 years. He is a founder and lecturer for the Infection Preventionist Boot Camp Series. For more information contact Mr. Stoker at info@isips.org.