2. The Problem
CDC estimates ~385,000 sharps injuries annually
among hospital-based healthcare personnel
(>1,000 injuries/day)
Many more in other healthcare settings (e.g., emergency services,
home care, nursing homes)
Increased risk for bloodborne virus transmission
Costly to personnel and healthcare system
3. Risks of Seroconversion due to Sharps Injury
from a known positive source
Virus
HBV
HCV
HIV
Risk (Range)
6-30%*
~ 2%
0.3%
(*Risk for HBV applies if not HB vaccinated)
4. What is the Risk for HIV Alone?
Percutaneous 0.3%
Mucous membrane 0.1%
Non-intact skin
<0.1%
5. Costs of Sharps Injuries
Baseline and follow-up laboratory testing
Treatment of exposed personnel
$71-~$5,000 depending on treatment provided
Lost productivity
Time to complete paperwork
Loss of income / loss of career
Emotional costs
Societal costs
O’Malley, et. al. Costs of Management of Occupational Exposure to Blood and Body Fluids.
ICHE, July 2007, v 28, No. 7.
8. When Do Sharps Injuries Occur?
During use 41%
After use/before disposal 40%
During and after disposal 15%
Other 4%
Source: NaSH, June 1995—December 2003
9. What Devices are Involved in Sharps Injuries?
Six Devices Account for 78% of All Injuries
Disposable Syringes 30%
Suture Needles 20%
Winged-Steel Needles 12%
Intravenous Catheter Stylets 5%
Phlebotomy Needles 3%
Scalpels 8%
Source: NaSH, June 1995—December 2003
10. How Do Injuries Occur With Hollow-Bore Needles?
During Sharps
Disposal
13%
During Clean Up
9%
In Transit to
Disposal
4%
Handle/Pass
Equipment
6%
Improper
Disposal
9%
Access IV Line
5%
Transfer/Process
Specimens
5%
Recap Needle
6%
Collision
W/Worker or
Sharp
10%
Manipulate
Needle in Patient
28%
Other
5%
Circumstances Associated with Hollow-Bore Needle
Injuries NaSH June 1995—December 2003
(n=10,239)
Disposal
Related:
35%
11. Sharps Injuries Are Preventable
Preventable
64%Nonpreventabl
e
18%
Undetermined
18%
Preventability of Needlesticks in 78 NaSH Hospitals,
June 1995--December 2004 (n=11,625)
13. How Can Needle Use Be Eliminated or Reduced?
Use needle-free IV delivery systems
Use alternate routes for medication delivery
and specimen collection when available and
safe for patient care
Streamline specimen collection systems
14. Needle-Free IV Delivery Systems
IV delivery systems
use valved ports and
connectors, pre-
pierced septa using
blunt cannulas, or
recessed protected
needle connectors
18. Injuries Related to Work Practices
Injuries occur because of the following:
Passing or transferring equipment
Recapping contaminated needles
Colliding with coworkers
Decontaminating/processing used equipment
19. Injuries occur from sharps left in
unusual places:
Laundry
Mattresses
Tables, trays, or other surfaces
20. The Sharps Safety Continuum
Prepare to use the device the moment the sharps
are first exposed
Take precautions while using sharps
Take precautions during cleanup
Take precautions during disposal
28. If using a fixed
sharps container it
should not be
fitted higher than
1.4 meter
29. Before the beginning of a procedure
that involves the use of a needle or
other sharp device:
Identify the location of the
sharps disposal container;
if moveable, place it as
near the point-of-use as
appropriate for immediate
disposal of the sharp.
If the sharp is reusable,
determine in advance
where it will be placed for
safe handling after use.
30. Before the beginning of a procedure that
involves the use of a needle or other sharp
device:
If multiple sharps will
be used during a
procedure, organize
the work area (e.g.
procedure tray) so
that the sharp is
always pointed away
from the operator.
31. During a Procedure That Involves the
Use of Needles or Other Sharp
Devices:
Maintain visual
contact with the
procedure site and
location of the sharp
device.
32. During a Procedure That Involves the
Use of Needles or Other Sharp
Devices:
When handling an
exposed sharp, be
aware of other staff in
the immediate
environment and take
steps to control the
location of the sharp
to avoid injury to
oneself and other
staff.
33. During a Procedure That Involves the Use of Needles or
Other Sharp Devices:
34.
35. During a Procedure That Involves the Use
of Needles or Other Sharp Devices:
If the procedure necessitates reusing a needle
multiple times on the same patient (e.g., giving
local anesthesia), recap the needle between
steps using a one-handed technique or a fixed
device that enables one-handed recapping.
40. Activate the safety feature as the procedure is being completed,
observing for audio or visual cues that the feature is locked in
place.
Safety
syringes
46. Use a mechanical device to
remove sharps from overfilled
box
If a sharps container
is overfilled, obtain a
new container and
use forceps or tongs
to remove protruding
devices and place
them in the new
container.
48. Improperly Disposed
Sharps:
If an improperly
disposed sharp is
encountered in the
work environment,
handle the device
carefully, keeping the
hands behind the
sharp at all times.
56. FLOW SHEET FOR NEEDLE
STICK/SHARPS INJURY
NEEDLE STICK/SHARPS INJURY
WASH THE INJURY UNDER RUNNING WATER
(DO NOT SUCK/SQUEEZE FROM THE INJURED
SITE)
COVER INJURY WITH AN IMPERMEABLE
DRESSING
NOTIFY SUPERVISOR
IF INJURY IS SERIOUS GO TO ER FOR
APPROPRIATE TREATMENT
57. FLOW SHEET
NEEDLESTICK/SHARPS INJURY
COMPLETE AN OVA FORM (INCLUDE
PATIENT/SOURCE MEDICAL NO.)
GO TO EHS WORKING HOURS/AFTER
WORKINH HOURS GO TO ER)
GO TO GP LAB FOR BLOOD WORKS
IF POSSIBLE DO BLOOD WORKS FROM SOURCE
PATIENT AFTER CONSENT FROM TREATING
PATIENT
GO BACK TO EHS AT THE SPECIFIED FOLLOW-
UP DATES GIVEN TO YOU FOR BLOOD WORKS
During this presentation we will talk about needlesticks and injuries with other sharps. We’ll first discuss why these injuries are a problem, how these injuries occur, and most importantly, how these injuries can be prevented.
CDC estimates that approximately 385,000 injuries with contaminated needles and other sharps devices occur annually among hospital-based healthcare personnel. That’s over 1,000 injuries a day! Many more occur in other healthcare settings, such as emergency services, home care, and nursing homes. Injuries with contaminated needles and other sharp devices are an important concern because they pose the risk of transmission of bloodborne viruses, and they are costly to personnel and to the healthcare system.
The three bloodborne viruses of primary concern for transmission from sharps injuries are hepatitis B (HBV) and C (HCV) viruses, and human immunodeficiency virus (or HIV), the virus that is associated with AIDS. The average risk of transmission after an occupational percutaneous exposure varies by the type of bloodborne virus. As you can see, one is at a higher risk for being infected with HBV following a sharps injury than for HCV or HIV. Fortunately, for hepatitis B virus, a vaccine and immune globulin are available that can protect healthcare personnel from becoming infected. This is why this vaccine is heavily promoted for healthcare personnel. The average risk for HCV transmission after a percutaneous exposure to HCV-infected blood is approximately 1 in 50 exposures. The average risk for HIV infection after a percutaneous exposure to HIV-infected blood is about 1 in 300 exposures.
For all bloodborne viruses, the percutaneous route of exposure (for example, a needlestick injury) carries the greatest risk for transmission of infection. The average risk for HIV transmission after a mucous membrane exposure (for example, blood splashed in the eye) is estimated to be 0.09%, or about 1 in 1,000. Although episodes of HIV transmission after skin exposures have been documented, the average risk for transmission has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures.
Although occupational transmission of HIV or hepatitis is relatively rare, the risks and costs associated with blood exposure are high. Some of the direct costs of sharps injuries are those associated with the initial and follow-up laboratory testing and treatment of exposed healthcare personnel. These are estimated to range between $71 to approximately $5,000, per person depending on the treatment provided. Costs that are harder to quantify include direct and indirect costs associated with potential side effects of antiretroviral therapies and lost time from work, time lost to completion of paperwork and follow-up (including obtaining informed consent for source patient testing), the emotional cost associated with fear and anxiety from worrying about the possible consequence of an exposure, and the societal cost associated with HIV or HCV seroconversion. By societal cost, I’m referring to possible loss of a worker's services in patient care, the economic burden of medical care, any worker’s compensation claims due to injury and exposure, and the cost of any associated litigation. [Note to presenter: Use local cost information if available.]
Because of the high burden of sharps injuries, our goal is to prevent – and ideally eliminate – sharps injuries.
Data from NaSH show that nurses sustain the highest percentage of percutaneous injuries. However other patient-care providers (such as physicians and specialized technicians), laboratory staff and support personnel (such as housekeeping and maintenance staff) are also at risk. [ NOTE to presenter: Depending on audience, the collective data can be used to elicit discussion on issues that contribute to this distribution: devices, training, staffing, disposal problems, etc. Ask audience members how they think injuries to housekeeping and maintenance staff occur. If the targeted group is primarily laboratory staff, you may want to include other bloodborne pathogens important to lab workers (See Workbook , Overview—Risks and Prevention of Sharps Injuries in Healthcare Personnel, Table 1).]
Injuries with needles and other sharp devices can happen at any time during use. NaSH data show that the majority of injuries occur during or immediately after use; 15% occur during or after disposal. During use injuries often occur when the device is being inserted or withdrawn and/or the patient moves. After use injuries occur during cleanup or in transit to another location. Injuries during disposal often involve Placing used sharps into the container or Disposing of a sharps devise inappropriately; that is, when a device is placed in the trash or left at the bedside or other location. In the next few moments, we will look in greater detail at how these injuries occur.
Think about all the needles and other sharp devices that are used to provide healthcare. While many different devices that can cause sharps injuries, six types account for nearly 80% of injuries in NaSH hospitals. Hollow-bore needles alone account for 56% of all sharps injuries. Hollow-bore needle injuries, especially from devices used for blood collection or for IV catheter insertion, are of particular concern, since they are likely to contain residual blood and are associated with an increased risk for bloodborne virus transmission. Of the 57 documented cases of occupational HIV transmission to healthcare personnel reported to CDC from June 1995 to December 2002, 50 (88%) involve percutaneous exposure . Of these, 45 (90%) were caused by hollow-bore needles and half of these needles were used in a vein or an artery. Although two scalpel injuries (both in an autopsy setting) caused HIV seroconversions, solid sharps such as suture needles or scalpels, generally deliver a smaller blood inoculum, especially if they first penetrate gloves or another barrier. Therefore these devices theoretically pose a lower risk for HIV transmission. Similar descriptive data are not available for type of devices or exposures involved in transmission of HBV or HCV.
You may also know that there are many possible mechanisms for injuries. In NaSH hospitals, 26% of hollow-bore needle injuries occur while the needle is being inserted, manipulated or withdrawn from the patient, and the patient moves or jars the device. Some needle injuries occur when accessing intravenous lines, such as giving an IV flush. With needle-free IV systems now available, these injuries should not be occurring. The same applies to recapping injuries. Why do you think people recap needles when it is so dangerous? [NOTE to presenter: Encourage discussion of this subject if time permits] You can see that many injuries in NaSH hospitals occur after use on the patient, such as during clean up, in transit to disposal, and during disposal. An additional 9% of injuries are due to improper disposal or result from leaving a sharp device on a table, stuck in a mattress, on the floor, or some other location. Another 10% of injuries occur when healthcare personnel collide with each other during a procedure. [NOTE to presenter: Encourage discussion of the different injury mechanisms, including some not mentioned here.]
Data from the NaSH system show that most sharps injuries from hollow-bore needles are preventable. A majority (64%) of all hollow-bore needle-related injuries can be prevented by using needles only when necessary, using devices with engineered safety features, properly using the safety features on these devices, following proper work practices (such as not recapping used needles), and properly disposing of needles after use.
As stated earlier, the first strategy in the hierarchy of sharps injury prevention is to reduce, if not eliminate, the unnecessary use of needles or other sharps objects when appropriate.
There are several ways that needle use can be eliminated or reduced. One way is the implementation of needle-free IV delivery systems that do not require, and in some instances, do not permit needle access. The majority (approximately 85%) of US hospitals have eliminated unnecessary use of needles through implementation of these devices. This strategy has largely removed needles attached to IV tubing, such as those for intermittent (piggy-back) infusion and other needles used to connect and access the part of the IV delivery system. Such systems have demonstrated considerable success in reducing IV-related sharps injures.
Here are two examples of needle-free IV delivery systems. As you can see all connections are made without the use of needles. Some systems use blunt cannulae (lower right) that enter the system through pre-pierced ports. Still other systems have recessed needles for system connections. [Note to Presenter: Discuss the safer IV delivery system that is used in your facility. When available, include a picture or have samples of the system on display.]
Some needle-free systems have been associated with bloodstream infections in patients. Therefore it is important to understand the infection control measures that should be adhered to, particularly the need for aseptic technique, when handling these systems.
The needs of patient care suggest that it will never be possible to eliminate the use of all needles and other sharps devices. Therefore, devices with engineered, or built-in sharps injury protection features aim to reduce the hazard to healthcare personnel.
This slide displays a variety of safer sharps devices engineered to prevent sharps injuries. On the left you see a variety of devices with the needle exposed in the before-use position. On the right you see that sharps are protected after use. The safety features include hinged caps [Note to presenter: point to devices #2 and # 7 from the top] , sliding sheaths [Note to presenter: point to devices #3, 4, and 6 from the top] , and retracting needles [Note to presenter: point to devices #1, 5, and 8 from the top] . Another type of safety feature, not shown here, is a bluntable phlebotomy or butterfly type needle. Additional strategies for needle protection are likely to evolve. [Note to Presenter: Identify whether any of these devices are currently in use or being evaluated by your facility. If other products are available, provide samples of them. Alternatively, create a slide with pictures of the devices used in your facility.] [ Disclaimer: The devices pictured in this slide are meant to serve as examples of devices that are currently available. This is not an exhaustive list, nor is it meant to favor one device over another. CDC and OSHA do not approve, endorse, register, or certify any medical devices.]
Many injuries related to work practices occur while sharps are being passed between different individuals, or transferred to a different location. Additionally, even though the practice of recapping contaminated needles has been discouraged for more than 20 years, approximately 5% of sharps injuries continue to occur due to recapping. Still other injuries related to work practices occur during collisions between workers and during decontamination or processing of used equipment. Personnel also continue to be injured by the improper disposal of used sharps. These injuries occur when sharps are left in unusual locations such as laundry or linens or are stuck in mattresses, left in pockets, or left on tables, trays, or other surfaces.
This slide summarizes the steps along the sharps safety continuum that will be reviewed in detail. Work practices to prevent sharps injuries are typically present as a list of specific practices to avoid (for example, recapping used needles) or to use (such as, sharps disposal containers). Data show that the risk of a sharps injury begins at the moment sharps are first exposed and ends once sharps are permanently removed from exposure in the work environment. Therefore, to promote safe work practices, healthcare personnel need to have an awareness of the risk of injury throughout the time sharps are exposed. They should also use a combination of strategies to protect themselves and their coworkers through the handling of the device. We will now review recommended practices that reflect this concept.
The recommended work practices that help ensure safety can be simplified into three quick points: Be prepared. Be aware. Dispose with care.
Before beginning a procedure that involves the use of a needle or other sharps device you should: ● Ensure that equipment necessary for performing a procedure is available within arm’s reach, and organize the equipment so that the procedure can be done safely. ● Assess the work environment before starting and make sure that you have adequate lighting and work space for the procedure. In cases where low light is needed for the procedure, take steps such as verbal cuing and the use of neutral zones to minimize the risk of injury from passing sharps. ● Ensure that the sharp object being used is always pointed away from the user.
