Getting to the Point of Sharps Safety Best Practices

Every year between 600,000 and 800,000 people are the victims of needlestick injuries in U.S. hospitals, according to the National Institute for Occupational Safety and Health (NIOSH). These numbers are daunting, but the stories behind the numbers are far more troubling.

Lisa Black, RN, MS, PhD, never thought shed be one of the statistics. At the time of her injury she was well aware of sharps safety procedures, but even knowledge is not always enough.

In 1997 Black was working a shift at a Nevada hospital when her life changed forever. She was tending several patients when she noticed that one of her patients IV tubes was backed up with blood, she says.

While I was gathering my supplies, I noticed that the IV line was not equipped with the needleless IV access system the hospital had available but had not consistently implemented to prevent needlestick injuries, Black says. The needleless system required special needleless adapters that were not always available on the units. I filled a preassembled syringeneedle device with a normal saline irrigation solution and inserted the needle into the rubber port on the IV line. I attempted to aspirate the coagulating blood from the occluded catheter and to flush the solution through the line.

The patients arms jerked. This dislodged the needle that was inserted through the rubber port of the IV line, and the needle punctured Blacks left palm.

And that was that. In a mere moment the 27-year-old mother of two became infected with HIV and hepatitis C. She didnt know that at the time, however.

Some co-workers assured Black that her chances of contracting an illness were slight, but just in case she began a regimen of potent antiviral and protease-inhibiting medications within two hours of exposure and for the next 30 days she took several other medications.1

They may have worked a little, but they didnt work enough. Nine months after the needlestick, Black discovered that she had contracted two terrible illnesses.

I was angry for a long time, but I now feel hope and optimism where once there was fear, she says. My experience can be viewed as one of tragedy and sadness, but its also one of opportunity. While my future remains uncertain, many doors have opened, including one that leads to advocacy on behalf of nurses safety. I am committed to the development of effective healthcare policies to protect healthcare workers from unnecessary workplace exposures to bloodborne pathogens.

Black is now an assistant professor at the Orvis School of Nursing at the University of Nevada in Reno and has been involved with the advancement of state and national legislation that creates safer healthcare atmospheres. Black speaks around the world about her experiences and has counseled many nurses who have faced needlestick injuries.

Thanks to mandates set forth by the Occupational Safety and Health Administration (OSHA), facilities are identifying dangerous tools and are replacing them with safer alternatives. Most facilities are doing a great job, Black says, but some are lagging.

Healthcare workers have a tendency to blame themselves for needlesticks even though they shouldnt, says June Fisher, MD, director of the Training for Development of Innovative Control Technologies Project (TDICT).

An occupational death or illness is the failure of a system, not an individual, Fisher says. It is also a systematic failure when a person does not report their situation or does not seek treatment.

You need to find out why theyre not reporting, Fisher says. Most of it has to do with people not having time to report if theyre going to have to sit in an emergency room for four or five hours.

Emergency rooms must be prepared for needlestick injuries and should give priority to starting treatment immediately for healthcare workers, Fisher adds. She suggests 24-hour coverage for treating sharps injuries through a combination of day time employee health services and an informed emergency room.

Healthcare workers who have been the victim of needlesticks should indeed be prioritized, says Angela Laramie, MPH, epidemiologist and project coordinator of the Sharps Injury Surveillance and Prevention Project, which is part of the Occupational Health Surveillance Program at the Massachusetts Department of Public Health.

After the injury occurs, the implementation of a comprehensive and timely post-exposure management program is important, Laramie says. This serves several purposes, the most important of which is making sure that the injured employee receives appropriate care. A streamlined post-exposure process may also have some effect on reporting culture within a facility.

A Good Plan

An effective sharps safety plan should always be evolving. It starts with proper tools such as safety syringes, says Jean McDowell, RN, vice president of clinical affairs at Inviro Medical Devices. She has worked extensively as a nurse in pediatrics and oncology.

A good plan requires tailoring sharps safety products to meet the needs of the end users, McDowell says. For instance, to use a different safety syringe in the operating room if the one generally used in the hospital does not function well in that application, she says. Too frequently the departments answer to lack of function is simply to disengage the safety feature.

Flexibility is key in the overall plan, and in the selection of products.

One product seldom meets the needs of every department and it may be necessary (even preferable) to use another product line in one or more departments if it enables the clinicians to perform their jobs safely and accurately, McDowell says. Annual review of safety sharps (is necessary) including new technologies to determine if current products best meet all departmental needs.

At least 50 percent of every sharps safety committee should be comprised of front-line healthcare workers, Fisher says.

The committee should also be given enough authority and resources to make real changes, such as acquiring proper sharps safety devices, Fisher adds.

Indeed, the inclusion of front-line staff is vital, according to Laramie. Conducting trials for a given length of time after training staff on all shifts in that unit has helped institutions to make purchasing decisions that are appropriate for their staff, Laramie says. Requesting written feedback through surveys allows facilities to gather data on an anonymous basis and allows decision makers to understand staff preferences.

Data may also be analyzed to determine which injuries occur with devices lacking safety features and then conducting a market search to find alternative devices with sharps injury prevention features, she adds. Data can be analyzed by department and occupation to help select devices that should be converted from conventional to those with safety features as well as helping to determine where to focus additional training or attention in the effective use of the device and its safety feature.

Caped Crusaders

Several organizations have formed over the years with the goal of reducing needlestick injuries. One such initiative is TDICT, which started in 1990. TDICT is based at the Trauma Foundation at San Francisco General Hospital and is a collaboration of healthcare workers, product designers, and industrial hygienists. The project was funded for 16 years through NIOSH.

Needlesticks and sharps injuries are the most common form of occupational transmission of bloodborne pathogens, and more than 250 healthcare workers die annually from occupationally acquired hepatitis B, TDICT researchers say. Prevention of needlestick injuries did not gain major focus, however, until OSHA released its Bloodborne Pathogens Standard, and until AIDS became a major threat, the researchers add.

Groups such as TDICT provide ample resources to facilities, such as criteria sheets for device evaluation, task analysis instruments to evaluate sharps use, and strategies for device assessment.

Best Practices

Effective sharps safety includes many small and large components. Experts recommend a combination of the following methods:

• Provide staff with hepatitis B vaccinations 

• Research safety products carefully 

• Use blunt retractors instead of sharp retractors whenever possible 

• Always activate safety features on tools before disposing them 

• Provide extra barrier surgical gowns for staff 

• Practice clear communication during surgical procedures by using terms such as, sharp up, sharp down

• Use puncture-resistant sharps containers 

• Make certain that incident report packets are as user-friendly as possible 

• Create an award for employees who have demonstrated above-average sharps safety adherence 

• Start a sharps safety education month or week at the facility 

• It is also advisable to choose pre-packaged kits wisely, according to Fisher, as some include better products than others.

Laramie agrees. Look at commercially-available prepackaged central line kits as a source of devices without safety features and work with kit packers and manufacturers to ensure that only devices with safety features are included in the kits, Laramie says.

One States Survey

The state of Massachusetts takes some things even more seriously than St. Patricks Day and clam chowder. Sharps safety receives clear focus there thanks to the Massachusetts Sharps Injury Surveillance System, which is a collaboration between hospitals, professional associations, community advocates and the Massachusetts Department of Public Health (MDPH).

The program initiates the collection of extensive statewide data. Employees of the MDPH review that data, provide education and spearhead surveillance efforts.

Until the year 2000, Massachusetts healthcare workers had very little needlestick data.2 The surveillance system was then started and now releases data annually in a comprehensive report.

The most recent report measures data from 2004. MDPH members warn that it is important to take into consideration that many needlestick injuries go unreported. Therefore, a facility at which employees feel comfortable reporting injuries may look like a more dangerous place than a facility where report rates are low.

The information has been helpful, Laramie says. Hospitals found that compliance with regulations led to changes that were welcomed by staff, she adds.

In 2004 acute-care workers in Massachusetts reported 3,279 sharps injuries. Eighty-five percent (2,776) of those who sustained injuries were hospital employees, 9 percent (310) were non-employee practitioners, 3 percent (83) were students, and 1 percent (35) were temporary or contract employees, the report claims.

Nurses were most likely to be injured, followed by physicians. Almost all of the physicians who were injured were interns or residents. Technicians and support service workers also sustained injuries. Technicians accounted for 20 percent (657) of injuries and support service workers accounted for 4 percent (123). Seventy eight housekeepers sustained injuries.

About 45 percent of needlesticks occurred in operating and procedure rooms, and 22 percent occurred in inpatient units.

The biggest culprit was the hollow-bore needle, which was involved in 56 percent (1,836) of all injuries. More than half of the injuries involving hollowbore needles occurred with hypodermic needles.

A little more than half of the injuries (1,773) involved standard devices (such as hypodermic needles) that did not have engineered sharps injury prevention features, even though hypodermic needles with safety features have been available on the market for more than a decade.

What Needs to Happen

Staffs should categorize all products, determine whether they are being used in the right places and whether they should be used at all. Safety syringe products generally fall into three categories, McDowell says. They include:

• Retrofit syringes, which are standard luer lock syringes and needles with a safety feature retrofitted to the basic syringe. This includes sheathed devices and needles with a variety of covers.

• Manual retractable syringes, which the user can retract manually into the barrel of the syringe by pulling the syringe plunger back.

• Automatic retractable syringes, wherein the needle is automatically retracted back into the barrel of the syringe, usually via a spring-loaded mechanism.

Retrofit syringes can be challenging to use, McDowell says, as the added needle cover sometimes interferes with vision and the actual injection.

Unfortunately, unless there is an alternative product, the user usually simply disengages or removes the safety feature in order to perform their work, thus increasing the risk of needle sticks, she says. Use of manual or automatic retractable syringes is a viable alternative to the retrofit in these cases. The choice between these two options is then based on cost and user preference.

Members of some organizations, such as the National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI), believe that the biggest priority in the fight against needlesticks is to eliminate the need for sharps whenever that is a viable option.

This goal is limited though, McDowell says. While the goal of eliminating the need for sharps is laudable, in reality it is probably not totally possible, she says. There are applications that, using current technology, simply cannot be performed needleless.

The Needlestick Safety and Prevention Act has motivated healthcare teams to focus more on sharps safety, but there is far more work to be done, McDowell says.

Not enough has been done in clinics, physician offices and for home use to significantly reduce the needlestick risks to the clinician, the patient and the community at large, she adds. This fact is brought into focus every time I read a newspaper article about dirty needles and syringes being found on a public beach.

For people like Lisa Black, no such reminder is necessary; she lives with it every day.

References 

1. Black L. From needlestick statistic to nurse advocate: an on-the-job injury led to HIV and hepatitis C infection. American Journal of Nursing. March, 2006.

2. Sharps Injuries among Hospital Workers in Massachusetts, 2004. Findings from the Massachusetts Sharps Injury Surveillance System. www.mass.gov/dph/ohsp. April, 2007.