Using Safer Devices, Following Hierarchy of Controls Can Cut Sharps Injuries

By Elizabeth Srejic

Occupational exposure to blood and body fluids (BBF) is a serious – even deadly -- hazard faced daily by many healthcare personnel.1-2 Percutaneous injuries from sharps, a well-known vehicle of bloodborne disease, contribute heavily to this important public health issue. In fact, an estimated 35 million workers worldwide are at risk of exposure to pathogens from sharps injuries sustained in a variety of healthcare settings and scenarios.3-4 Such exposures, although preventable, are often regarded as “just part of the job.”5 

The potential dangers of working with sharps are real. The World Health Organization (WHO) estimates that 9 percent of the healthcare workforce are exposed to bloodborne pathogens every year,6 while the Centers for Disease Control and Prevention (CDC) puts the annual number of sharps-related injuries among hospital healthcare workers (HCWs) at about 600,000.7 Furthermore, these statistics and others like them may be the tip of the iceberg as at least half of sharps injuries may go unreported.8-11

More than 40 pathogens may be spread through BBF exposures.12 Hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) are three bloodborne viruses spread this way; of these, the most commonly transmitted is hepatitis B.13-14 Bacteria spread through sharps and BBF exposure have potential to be multi-drug-resistant species which are potentially linked to prolonged illness and poor health outcomes.15

“Why sharps injuries are dangerous may seem like a pretty basic question but it isn’t,” says Amber H. Mitchell, DrPH, MPH, CPH, president and executive director of the International Safety Center. “With emerging and re-emerging global infectious diseases, as well as global travel and immigration, sharps injuries related to patient care are more dangerous than ever -- consider the Ebola cancers that happened in Dallas a year and a half ago, emerging pathogens like the Zika virus, re-emerging infections like measles and rising rates of hepatitis C.”

Sharps not only injure HCWs but the costs involved with managing exposure are injurious to the healthcare industry. Direct and indirect costs surround the time spent reporting, treating and following cases; salaries and benefits for injured staff members; laboratory testing of exposure sources and exposed personnel; and post-exposure prophylaxis.16 And the human costs, such as emotional distress and life-changing illness, are also steep.17

Policy-making in the U.S. surrounding occupational exposure to bloodborne pathogens arose in in response to the HIV epidemic in the 1980s.18 Since then, regulatory and legislative action has slowly progressed while exposure has waned.19 In 1991, the Occupational Safety and Health Administration (OSHA) issued its Bloodborne Pathogens Standard which required employers to adopt certain engineering and work practice controls to eliminate or minimize employee exposure to bloodborne pathogens, which included offering Hepatitis B vaccination at no cost to employees at reasonable risk of exposure to blood or other potentially infectious materials.20-21 In 2000, Congress passed the Needlestick Safety and Prevention Act to revise the standard; it required employers to update their exposure control plans, consider using safety-engineered devices (SEDs) whenever possible and keep a sharps exposure log, among other requirements.22 Since then, injuries in all healthcare settings have declined by 38 percent overall and sharps injuries specifically have also declined.23
Percutaneous BBF exposures occur in a range of settings and circumstances. Over the years, research has sought to identify, measure and analyze influential variables in these exposures, and healthcare facilities have considered those findings in developing injury prevention strategies. Initially, the who, what, when, where and why of occupational exposures were identified and monitored in individual studies using surveys and questionnaires or retrospective reviews. In general, the setting, scale and other characteristics of these studies were diverse, although most reported that physicians, nurses and less-experienced personnel were at highest risk of sharps injuries;24-27 most injuries were associated with hollow-bore needles28 and happened during injection and suturing29 or after using the device, as with recapping needles or disposing of sharps;30-32 in addition, the majority of sharps and BBF exposures occurred in the operating room (OR).33-34

Studies reporting and analyzing statistical data on sharps and BBF exposure have become less common following the emergence of EPInet™, a data surveillance system which supplanted most methods of data collection and analysis used at the time. According to the International Safety Center, EPInet™ continuously gathers data on sharps injuries and BBF exposures which it shares with the public in two annual reports.35 The reports contain exhaustive lists of specific variables of interest in sharps and BBF exposures and their average measurements which are calculated from data provided by a group of representative U.S. hospitals. The data permit comparisons such as the relative influence of specific characteristics in sharps injury trends and other analysis. EPInet™ can also be used by individual facilities for internal surveillance.

EPInet™ has been in place since 1991, and it is what Janine Jagger, MPH, PhD, created out of the University of Virginia,” says Mitchell. “It’s a surveillance system used by hospitals around the world to record all occupational events of BBF exposures, which includes sharps injuries. The data comes from an aggregate of hospitals in the United States that contribute to the pubic EPINET system which serves as the benchmark for the rest of the nation on sharps injuries – where and how they’re occurring. It allows the public stay aware of what’s continuing to happen with sharps safety in healthcare facilities. It is really the only sharps surveillance system out there, so there’s not a lot of motivation for people to continue publishing on sharps safety.”

According to EPInet™ data reported by the CDC, sharps injuries occurred most frequently while the device was being used; the second most likely period was during activities after using the device but before disposal, and the third was during disposal-related activities.36 And devices most commonly involved include disposable syringes, followed by "other sharp items," suture needles, winged steel needles, "other needles" as well as disposable and reusable scalpels (tied), and IV catheters as well as syringes with prefilled cartridges (tied).37

Existing and emerging reports have also shown that HCWs are at greatest risk of sharps and BBF exposures in surgical environments, and research continues to explore injury prevention in those settings.38 The complexity of the surgical environment is generally regarded as the reason why HCWs so frequently sustain injuries there,39-40 and analyzing general and facility-specific factors are is important in developing injury prevention protocols.41

Recent research in this area by Myers, et al. (2016), a 10-year retrospective cohort study with data collected at an academic teaching hospital, reported new findings surrounding the risk of percutaneous BBF exposures occurring in ORs.42 A total of 2,113 exposures were reported over the course of one year; exposures involving suture needles were examined separately from those involving other device types to examine possible differences in risk factors. The overall rate of reported BBF exposures was 6.3 per 1,000 surgical procedures, and rates increased with estimated patient blood loss, number of personnel working in the surgical field during the procedure as well as procedure duration, and these associations were generally stronger for suture needle-related exposures.43
Other notable research examining potential factors in exposure in surgical settings was conducted by Jagger, et al. (2011) using surveillance data obtained from 87 U.S. hospitals from 1993 through 2006, although the main goal of the study was to compare injury rates in surgical and nonsurgical settings before and after the Needlestick Safety Act. The authors reported a total of 31,324 total sharps injuries, 7,186 of which were to surgical personnel. Most injuries were caused by suture needles (43.4 percent), scalpel blades (17 percent), and syringes (12%), and 75 percent of injuries occurred during using or passing of devices. Surgeons and residents were most often the original users of the injury-causing devices, while nurses and surgical technicians were typically injured by devices originally used by others.44

The American College of Surgeons (ACS) recommends using double gloving and passing instruments, a hands-free zone and blunt-tip suture needles in the OR to increase safety and decrease injury.45 Wearing PPE such as eye protection to protect against splashes is another important strategic precaution in this setting, as are using SEDs whenever possible and safety-engineered disposal containers.46-48

“Healthcare personnel are at increased risk for sharps injuries in surgical settings because surgical procedures involve invasive activities,” Mitchell says. “The greatest risk of sharps injury is within the immediate operative area where many activities involve sharps. The most common scenario is suturing and cutting with needles and scalpels. Nursing and technical staff such as nursing techs and OR techs are probably at highest risk in the operating room surgical setting. And sharps injuries are not the only concern by far; splashes and splatters – especially to the unprotected eye – are extremely important. The concern at that point is not just exposure to bloodborne pathogens – it’s also about anything transmissible through the mucus membrane of the eye, like multi-drug-resistant pathogens. Scalpel blades and suture needles are probably two of the devices with SED technology that isn’t as far along in terms of safer features. Also, the currently available SEDs used for suturing and cutting tend to be used less frequently non-SEDs in these two types of sharps, which means increased risk. And, on top of that, you have multiple people around the operative field at the same time, so we’ve seen a lot injuries occurring not only in the device user but in other members of the surgical team. Also, in surgical procedures, emergency situations involve people rushing and there’s also a high volume of blood which can result in some high-velocity splashes or splatters on surgical personnel that aren’t even around the operative site. We’ve seen eye exposures happen to individuals standing five to 10 feet away from the patient.”

The CDC estimates that 62 percent to 88 percent of sharps injuries can be prevented simply by using safer medical devices.49 Little wonder, then, that using SEDs is not only an important – but also mandatory -- means of preventing percutaneous exposures in the United States and most industrialized countries.(50) Since 42.9 percent of SEDs injuries, which are preventable, reportedly occur after the device is used, HCWs should use extra caution when handling SEDs during that stage.51

Typical SEDs include needles and scalpels with passive or active safety systems. In active systems, the safety features of the device must be manually activated or the user will not receive protective benefit.52

“Using SEDs is important but the activation of safety features in those devices is critical,” Mitchell says. "People are using SEDs but they’re not activating the features that protect them from the sharps. For instance, after you give an injection, you have to actually do something to make yourself protected. You have to push a button or move a lever or cover with a shield. Also, frontline employees – the nurses, doctors, techs or other personnel actually using these devices – need to be on the evaluation team for SEDs to increase both the safety of the user and user comfort in activating the safety feature. Also, if a device is changing technologically or being replaced with a different SED, continual evaluation is needed so that HCWs remain aware of how to activate the device safely and choose devices that are appropriate to the procedures being done.”

Currently available SEDs are expanding in variety and number as technologies emerge and improve. Newer technologies include needless approaches such as jet injection, mucosal vaccination, and vaccine delivery via the skin, as well as novel approaches like cutting tissue with electrosurgical plasma induced with pulsed radio-frequency energy.53-54

Another way to mitigate risk and prevent incidence of sharps injury and BBF exposure, according to Mitchell, is following the hierarchy of controls concept, an injury prevention model consisting of five key guidelines ranked in order of importance: 1. Elimination of hazard, 2. Engineering controls, 3. Administrative Controls, 4. Work practice controls, and 5. Personal protective equipment (PPE). The system, which is used across industries, outlines and serves as a reminder of crucial practices that must be observed by workers and administration to prevent injury.

In healthcare, the hierarchy is adapted to sharps injury prevention, and, according to WHO, the first of the adapted five guidelines, elimination of hazard, involves eliminating use of a sharp, using needle-less systems, and avoiding unnecessary injections as much as possible; the second, engineering controls, involves using SEDs such as needles that actively or passively retract, sheathe or blunt immediately after use and safety-engineered sharps containers; the third, administrative controls, involves allocating resources to and implementing policies and programs that demonstrate commitment to HCW safety -- such as needlestick prevention committees and education and training on SEDs -- as well as policies and procedures that outline, monitor and enforce universal (standard) precautions; the fourth, work practice controls, refers to good practices in handling sharps such as not recapping needles, placing sharps containers at eye level and at arm’s reach and emptying sharps containers before they are full; and the fifth, PPE, simply reinforces that HCWs need to use mandatory devices that provide barriers and filters between themselves and hazardous situations such as gloves, shields and gowns.55

“For healthcare personnel, No. 1 in the hierarchy of controls is eliminating the sharp whenever possible,” Mitchell says. “No. 2 is use SEDs whenever possible. No. 3 is to use no-hands passing technique, or passing a contaminated sharp not by hand, but by placing it onto a surface in a safe zone like a tray for the other person to pick up. No. 4 is really good communication: ‘This is what I’m going to use, this is when I’m going to use it,’ and so forth. The team needs to be alerted when someone is using a device that could potentially result in an injury. And No. 5 reminds personnel to wear appropriate PPE.”

At the administrative level, facilities should do their part to protect employees from sharps and BBF exposures by developing and implementing strategic initiatives. Healthcare facilities should focus on re-evaluating and updating their occupational safety and injury prevention guidelines, monitoring systems used in tracking HCW compliance, and their exposure reporting and control protocols.56 

Implementing educational and training programs on general precautions, using facility-specific SEDs correctly, safe disposal of devices and other topics is an important consideration in injury prevention plans.57-58 Healthcare facilities should also update and enforce reporting strategies as part of their injury prevention programs.59

Another consideration in developing tailored preventative strategies is quality of the work environment, which can be influenced by staffing levels and other working conditions. Poor organizational climate and high workloads have been associated with 50 percent to two-fold increases in the likelihood of sharps injuries and near-misses to hospital nurses.60 Also, a growing body of research also describes the impact of physical and emotional limitations like fatigue and stress, upon exposure rates.61

Healthcare facilities should use some form of surveillance to monitor facility-specific trends in sharps injuries and BBF exposures.(62) One way is to maintain an exposure log for incidence reporting, listing where and how an injury occurred as well as the type and brand of device used, which should be regularly reviewed to identify trends, possible flaws in design and behavior patterns.63-65 Post-exposure plans should also involve evaluation, counseling, treatment and follow-up of the exposed individual.66 Common reasons for not reporting are believing that the risk of infection from the exposure is low, inadequate understanding of reporting systems and assuming that reporting is difficult.67

“In the future, important considerations include enforcing compliance at the facility and even industry level as well as funding for worker health and safety initiatives,” Mitchell says. “Also, risk management and injury prevention should be expanded into a broader safety system that protects not only the device user but other HCWs like the waste disposal worker collecting sharps disposal containers and the laundry worker finding used needles in the laundry. Holistic, cross-functional approaches like these are going to be important moving forward.”

Elizabeth Srejic is a freelance writer.

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