Between 2002 and 2005 one study has indicated that there has been a 46% increase in percutaneous injuries involving hollowbore needles. While this may partially be due to improved reporting, the trend indicates that this is an issue that needs focused attention for the protection of staff and patients.
In the USA, 600,000 to 800,000 needlestick and other percutaneous injuries among healthcare workers are reported annually. This, along with the observation that in at least one urban hospital 20–38% of procedures involved exposure to bloodborne virus, indicates the scale of the problem. While most attention is rightly focused on hepatitis B, hepatitis C and HIV, there are approximately 20 other infections that can be
transmitted by needlestick injuries.
There is also risk from fear of the problem itself – namely in stress to the healthcare worker and their families, leading to chronic post-traumatic stress. While the focus here is on the member of staff, the effect on the patient should also be considered. In an environment where patients exert increasing choice, incidents such as needlestick injuries may affect patient confidence.
In the past few years, suppliers and manufacturers have made substantial advances in technology that aim to reduce the incidence of needlestick injuries, particularly in high-risk procedures such as intravascular cannulation, venepuncture and injection. Advances have included:
- Phlebotomy devices with retractable needles
- Sample devices with concealed needles.
- Scalpels with retractable blades and shields.
- Lancets with tips that extend and retract.
- Syringes with retractable needles and sliding sleeves.
- Blunt-tipped suture needles.
- Gloves that are less likely to tear.
- Safer needles and sharps disposal.
It is recommended that standard safety procedures, or universal procedures, are adopted. These include:
- Handwashing after each patient contact.
- Wearing suitable disposable gloves whenever working with blood or body fluids.
- Covering cuts and abrasions with waterproof plasters.
- Immediately and safely disposing of sharps in approved puncture-proof bins.
- Never resheathing needles.
- Providing personal protective equipment, such as visors, goggles and aprons, where there is a risk of splashing from flying contaminated debris.
- Actions to be taken after a needlestick injury, such as washing the affected part of the body under running water and the availability of post-exposure prophylaxis to minimise viral transmission.
The most common cause of needlestick injury is noncompliance with these principles.
Although the adoption of both technological solutions and universal procedures makes a substantial contribution to reducing needlestick injuries, it is not the whole story. For example, in one study, where safer needle technology was introduced in a set of standard procedures in the field of blood donation, while there was an initial dip in the number of needlestick injuries reported, this was followed by a longer and more sustained increase. To rely on technology or universal procedures alone is problematic.
Consider the wide array of occupational settings where needlestick injuries can occur – for example, in the operating theatre, the emergency room, the ward, but also in the community and ambulance. A solution that might make sense in one environment might lead to problems in others. Or it may simply be unworkable, leading to staff finding their own informal solutions.
Also, there are the different groups of staff exposed to the risk. Staff in the early years of their career are particularly at risk, with one study indicating that 83% of surgeons had a needlestick injury during training. A practice to reduce needlestick injuries that may be second nature to one group of staff may be very new to others.
The application of universal procedures and technologies needs to be tailored to the hospital or organisation and to what people actually do when they are exposed to a bloodborne virus. A policy of “implement and forget” will not deliver the results. The involvement and consultation of staff in selecting the equipment to reduce needlestick injuries, in the development of procedures and in carrying out training have been seen as the most critical factors to the successful roll-out of a programme to reduce needlestick injuries.
The Centers for Disease Control and Prevention have produced a workbook focused on the critical organisational and workplace issues that are essential in implementing long-term and sustainable improvements in needlestick injury prevention. The fundamental approach is straightforward: consider the needs of the organisation, involve all the relevant stakeholders (particularly staff), develop an achievable plan with measures, and involve those who will be exposed to the risk in developing the procedures and selecting the equipment.
Once action has been taken, keep a track on progress to ensure that improvements are being made and sustained. Pay particular attention to individual departments and groups of staff to make sure the solutions are correct for the task and that there is a culture that takes the prevention of needlestick injuries seriously. Above all, it requires visible and committed engagement by those in senior leadership roles.
Careful analyses of needlestick injuries, both in terms of accident reports and from talking to staff, are likely to reveal a number of issues that require attention, and decisions may be needed to choose where attention should be directed. Factors that may affect this include not only the number of needlestick injuries but also the risk or prevalence of bloodborne virus among the patients being treated, the nature or vulnerability of the staff, and the environment and nature of the procedures.
The implementation of a new reporting system, or even highlighting the existing one, will often result in a decrease in apparent performance, not on the basis of actual deterioration, but due to increased reporting. It is therefore important to manage the expectations of all those involved, preferably from the outset.
Having established an organisational approach and commitment to reducing needlestick injuries, the following hierarchy can be applied to workplaces, procedures and staff:
- If possible, a non-sharp hazard should be used (eg, replacing glassware in a laboratory with plastic). If this is not possible, then:
- Use a device that reduces the chance of a needlestick injury (eg, a syringe that retracts its needle after use), and then consider:
- Looking at working practices/environment (eg, changing the layout in a surgery to minimise the handling and distance of a sharp from use to disposal), and then to consider:
- Training that is focused on what people actually do and what they need to do to reduce the chance of a needlestick injury.
Long-term success will depend on keeping needlestick injury prevention a high priority. This can prove challenging, particularly when the accident rate starts to decrease and attention shifts onto the next problem. From the start, accountabilities and responsibilities are important. Staff should be held responsible for their actions, both to prevent needlestick injuries and to report concerns and accidents. Responsibilities should also extend to supervisors, managers, clinicians and senior managers to make sure that the working environment is safe, as are their work practices, and that actions to reduce needlestick injuries are regularly reviewed.
If the worst happens…
While the focus is rightly on the prevention of needlestick injuries, procedures are still required when accidents do happen. Staff must know what to do the moment a needlestick injury occurs. Likewise, it is important that there is immediate clinical support to identify the clinical risk of bloodborne virus infection and access to post-exposure prophylaxis where required.
It is also important that there is suitable counselling support for staff who might find a needlestick injury and its possible consequences traumatising, particularly those new to a clinical environment.